COMMISSIONING DIVISION - Tameside _ Glossop NHS - Tameside and .doc

Document Sample
COMMISSIONING DIVISION - Tameside _ Glossop NHS - Tameside and .doc Powered By Docstoc
					Clinical Governance
 Development Plan

    Out-turn Report
(as at 31st March 2009)
Document Control Page



  Document                      Author                                   Comments                                      Date
   Version
0.1                 H. P. Harrisson & PCT wide        Initial draft for comments by contributors to the   20th January 2009
                    Contributors                      plan

0.2                 H. P. Harrisson/L. J. Lowe        Documented formatted and proof read –               31st March 2009
                                                      numerous minor amendments made

0.3                 H. P. Harrisson                   Draft to Clinical Governance meeting for final      21st May 2009
                                                      approval.

0.4                 H. P. Harrisson                   Ratified by PEC.                                    22nd July 2009




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                             1
KEY LEADS AND CONTRIBUTORS


               Rob Anker                      :       Records Manager

               Julie Annakin                  :       Immunisation and Vaccination Co-ordinator

               Clive Bass                     :       IT Service Manager

               Melanie Birtles                :       Legal Contracts Manager

               Debbie Bishop                  :       Service User Manager

               Janet Bunyan                   :       Primary Care Development Manager

               Mary Callan                    :       Primary Care Development Manager

               Hitesh Chandarana              :       PALS Manager

               Colin Cohen                    :       Head of Information Management and Technology

               Ben Dearden                    :       Head of Informatics and Business Intelligence

               Dr. J Doldon                   :       GP Lead, Medicines Management Committee

               Dr. Alan Dow                   :       PEC Clinical Governance Lead

               Naomi Duggan                   :       Director of Public Affairs

               Brian Durgan                   :       Dental Advisor

               Dr. R Fitton                   :       Salaried GP and Caldicott Guardian

               Kath Fitzgerald                :       Designated Nurse, Safeguarding Children

               Sabrina Fuller                 :       Consultant in Dental and General Public Health
NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009      2
               Hilary Garratt                 :       Director of Nursing and Provider Services

               Judith Grigg                   :       Associate Director, Provider Services

               Marion Gilchrist               :       Acting Healthcare Governance Facilitator

               Jan Grime                      :       Clinical Governance Community Pharmacy Facilitator

               Raj Gulati                     :       GP and Clinical Lead, Map of Medicine

               John Hanson                    :       Associate Director, Provider Services

               Heather Harrisson              :       Associate Director of Clinical Governance

               Lee Hawksworth                 :       Care Pathway Redesign Manager

               John Hazelhurst                :       Head of Adult Joint Integrated Commissioning

               Margaret Hayes                 :       Macmillan Community Nursing Sister

               Peter Howarth                  :       Associate Director/Head of Medicines Management

               Dave Hulme                     :       Risk Manager

               Margaret Hyde                  :       Communications Manager

               Nikki Leach                    :       Associate Director, Provider Services

               Alison Leigh                   :       Assistant Programme Director

               Lynda Lowe                     :       Clinical Governance Manager

               Kathryn Magson                 :       Director of Planning and Performance

               Dr Anna Moloney                :       Consultant in Public Health


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009          3
               Anita Maniak                   :       Dental Support Officer

               Joanne Marshall                :       Director of Human Resources

               Joanne Marvell                 :       Equality and Diversity Manager

               Hilary May                     :       Head of Patient Management

               Steven Mayer                   :       Optometrist

               Zoe Mellon                     :       Acting Head of Business Development and Performance

               Philip Owen                    :       Optometrist

               Heather Palmer                 :       Guidelines Implementation Manager

               Kathy Powys                    :       Associate Director, Provider Services

               Louise Rigg                    :       Deputy Director of Finance and Health Strategy

               Louise Roberts                 :       Strategic Project Manager

               Dr. Anne Rothery               :       Medical Director

               Michelle Rothwell              :       Head of NHS CHC/NHS FNC

               Chris Ryan                     :       Head of Estates

               Collette Saunders              :       Clinical Lead for Infection Control

               John Schooling                 :       Associate Director, Provider Services

               Mark Shrimpton                 :       Associate Director of Contract Management, Procurement and Performance

               Mark Simon                     :       Head of Risk & Complaints

               Elaine Simpson                 :       Contractor Services Manager

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                              4
               Melanie Sirotkin               :       Director of Public Health and Health Strategy

               Dr. Gideon Smith               :       Consultant in Public Health Medicine

               Karen Smith                    :       Patient Services Manager

               Jayne Southworth               :       Practice Nurse Co-ordinator

               Pauline Sumner                 :       Gold Standards Framework/Integrated Care Pathway Project Manager

               Chris Wallace                  :       Head of Information Governance

               Charles Wass                   :       Clinical Governance Optometry Representative

               Claire Watson                  :       Programme Director Health and Service Redesign

               Peter Welsby                   :       Pharmaceutical Adviser

               Kay Worsley-Cox                :       Assistant Director, Organisational Development, Training, Education and Life Long Learning




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                  5
              “Clinical Governance is a process – indeed, more than a process.                      It‟s an
              organising principle, a state of mind, the day-to-day, flesh and blood
              embodiment of how we practice – acting together across the traditional
              boundaries of our different roles and responsibilities; concentrating our will to
              care, the skills we have acquired, and the resources at our disposal – in order to
              give our patients – all of them, whatever their means, wherever they are – the
              best and safest care that a good health service can deliver.”




               “Clinical Governance is about our organisational conscience, our DNA, the
               things we do when we‟re not being supervised; it‟s about remembering when
               and what we first came here for …”




        (Sir Liam Donaldson speaking on the subject „Making quality count in today‟s NHS‟, 12th December 2003)




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                6
First Domain - Safety


Domain Outcome: Patient Safety is enhanced by the use of healthcare processes, working practices and systematic activities that
prevent or reduce the risk of harm to patients

   Development/                  Key Aim/Objective                    Lead          Target Date        Performance Measure             Reported Progress
      Topic                                                         Person(s)
COMMISSIONING
DIVISION

National      Patient Ensure integration of NPSA Mark Simon                         Ongoing         Evidence that „Seven Steps to "Seven Steps to patient
Safety Agency (NPSA) initiatives into risk management                               during          Patient Safety‟ is addressed Safety” guidance currently
                      work programme.                                               2009/10         within training materials.     being incorporated into
                                                                                                                                   risk management activity
                                                                                                                                   on an ongoing basis.
                                                                                                                                   Work to be rolled over into
                                                                                                                                   2009/10.
Health & Safety            Ensure integration of robust Mark Simon                  Ongoing         Evidence       that    updated Health and Safety training
                           Health and Safety activity to                            during          national health and safety provided to all new staff
                           support the PCT and satisfy                              2008/09         guidance is incorporated into via induction, and to
                           statutory requirements.                                                  training      materials    and existing staff under a 2-
                                                                                                    guidance issued locally – year rolling programme.
                                                                                                    annual audits and regular The third 2-year refresher
                                                                                                    monitoring of locations and cycle          of     training,
                                                                                                    procedures undertaken.         commenced                 in
                                                                                                                                   September 2008 and will
                                                                                                                                   be      ongoing      during
                                                                                                                                   2009/10.

                           Undertake health and safety Mark Simon                   September       Production of internal audit Achieved, but requires
                           audit of arrangements across                             2008            report.                      updating to ensure full
                           the PCT in light of the                                                                               implementation of the
                           Corporate Manslaughter Act                                                                            recommendations
                                                                                                                                 highlighted in the Internal
                                                                                                                                 Audit Report, by 30/06/09.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            7
   Development/                  Key Aim/Objective                    Lead          Target Date        Performance Measure              Reported Progress
      Topic                                                         Person(s)
Clinical Risk              Review    the   operational Heather                      By July 2008    Operational group structure Revision    of   Terms     of
Management                 aspects of the Clinical Risk Harrisson                                   reviewed and Terms       of Reference            almost
                           Management Group                                                         Reference agreed            complete.        For    final
                                                                                                                                approval by CRM Task
                                                                                                                                Group in May 2009.
Records                    Complete the implementation Mark Simon/                  June 2008       Updated      Action    Plan Records       Management
Management                 of   Records   Management Rob Anker                                      produced detailing actions Action Plan drawn up
                           Action Plan.                                                             addressed and implemented. following StfBH declaration
                                                                                                                                2006/07 has been largely
                                                                                                                                implemented.           Work
                                                                                                                                ongoing to enhance the
                                                                                                                                quality      of     records
                                                                                                                                management across the
                                                                                                                                PCT, to address all aspects
                                                                                                                                of clinical and non-clinical
                                                                                                                                records.

                           Continue to enhance the PCT‟s Mark Simon/                Ongoing         Evidence of enhanced score Score for 2007/08 – 65%.
                           position in regard to the Rob Anker                      during          of IG Toolkit for 2008/09 by 31st Work ongoing with a score
                           records management aspects                               2008/09         March 2009.                       of 70%, and expected to
                           of the IG Toolkit.                                                                                         be    rolled over     into
                                                                                                                                      2009/10.

Standards for Better Develop the use of the Mark Simon                              Ongoing         Evidence of production of PA in use for risk register.
Health Annual Health Performance        Accelerator                                 during          comprehensive reports from Development work for
Check                electronic system in order to                                  2008/09         the PA system and their StfBH ongoing.
                     assess     compliance     with                                                 consideration by Board and
                     standards.                                                                     Sub-Committee.

                           Submit draft declaration to Mark Simon                   March 2009      2008/09 draft declaration and Final         declaration
                           Board and final declaration to                                           final declaration produced in submitted to HCC March
                           HCC.                                                                     accordance with Healthcare 2009.
                                                                                                    Commission timetable.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             8
   Development/                  Key Aim/Objective                    Lead          Target Date       Performance Measure              Reported Progress
      Topic                                                         Person(s)
Incident reporting         Production of performance Mark Simon                     Ongoing         Reports produced quarterly      Reports    submitted      to
                           indicators for incidents, (both                          during          for     Governance       Sub-   Integrated    Governance
                           staff and patients), and to                              2008/09.        Committee – evidence from       Committee and Service
                           ensure these are acted upon                                              Governance Sub-Committee        Leads, at least bi-monthly.
                           by Integrated Governance                                                 minutes that specific issues    Detailed work on falls
                           Committee.                                                               are identified and addressed.   reduction ongoing.
                                                                                                                                    Detailed risk mitigation
                                                                                                                                    work on other issues
                                                                                                                                    identified by Integrated
                                                                                                                                    Governance Committee
                                                                                                                                    from incident reports to be
                                                                                                                                    undertaken.

NHS           Litigation Assess the PCT‟s compliance Mark Simon                     September       Timely reports submitted to Standards have recently
Authority Standards      with NHSLA standards for PCTs                              2008            Governance Sub-Committee been released following
                                                                                                    on compliance position.     pilot studies. Work locally
                                                                                                                                ongoing to address these.

 NHS           Litigation Assist managers in addressing Mark Simon                  December        Evidence that gaps identified
Authority     Standards potential gaps.                                             2008            and work undertaken with
(Cont’d.)                                                                                           relevant managers.

                           Prepare for NHSLA inspection.          Mark Simon        February        Portfolio of evidence drawn     Formal inspection not now
                                                                                    2009            up and linked to electronic     to take place in 2009/10.
                                                                                                    documentation         where     Work rolled forward into
                                                                                                    possible.                       2010.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             9
   Development/                  Key Aim/Objective                    Lead          Target Date       Performance Measure            Reported Progress
      Topic                                                         Person(s)
Complaints                 Implementation of         „Learning Mark Simon           Ongoing         Complaints responses detail   Key    aim/objective    for
Management                 from Complaints‟.                                        during          changes made to services      2009/10 to implement new
                                                                                    2008/09         where          appropriate.   National        Complaints
                                                                                                    Supplementary evidence of     Regulations. Target date
                                                                                                    ongoing             service   by September 2009.New
                                                                                                    improvements   via   action   regulations not yet laid
                                                                                                    plans      and        other   down      nationally.  Risk
                                                                                                    documentation.                Management Department
                                                                                                                                  currently formulating draft
                                                                                                                                  procedure, with reference
                                                                                                                                  to the work undertaken by
                                                                                                                                  early adopter sites.

Management         of Review and amend Serious Mark Simon                           30/06/08        Recommendations addressed Draft will be submitted to
Serious      Untoward Untoward Incident Policy to                                                   within revised policy.    next Emergency Planning
Incidents (SUIs)      reflect the recommendations                                                                             Group,       and       then
                      of Provider and Commissioner                                                                            Integrated    Governance
                      reviews relating to infection                                                                           Committee.
                      control arrangements.                                                                                   Achieved. Policy for the
                                                                                                                              external Monitoring of StEIS
                                                                                                                              Incidents formulated and
                                                                                                                              approved.         To     be
                                                                                                                              implemented from April
                                                                                                                              2009.

                            Put in place arrangements to Mark Simon                 30/06/08        Regular reports to Integrated Work remains ongoing.
                            capture information on serious                                          Governance        Committee
                            incidents occurring in external                                         detailing external provider
                            providers and to monitor                                                SUIs and associated action.
                            action taken.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         10
   Development/                  Key Aim/Objective                    Lead          Target Date        Performance Measure              Reported Progress
      Topic                                                         Person(s)
Registration of Health Ensure   the    GP     appraisal Anne                        Ongoing         Process      agreed       with Carrying out PCT self-
Professionals          process supports the White Rothery                           rolling         stakeholders in place.         assessment, assuring
                       Paper, „Trust, Assurance and                                 programme                                      quality medical appraisal
                       Safety – The Regulation of                                                                                  for revalidation.
                       Health Professionals in the 21st                                                                            All underway, awaiting
                       Century (DH 2007).                                                                                          e-template from National
                                                                                                                                   Revalidation Support
                                                                                                                                   Team.
Management       and Develop systems to support Ben Dearden                         05/05/08        Reports available to compare Patient Experience clinical
Reporting of Clinical management of clinical quality                                                clinical quality indicators to indicators have been
Quality Negligence    indicators.                                                                   contracted standards.          included within key
                                                                                                                                   contracts, such as TGH
                                                                                                                                   contract, in line with
                                                                                                                                   CQUIN requirements.
                                                                                                                                   Business Intelligence to
                                                                                                                                   support the collection and
                                                                                                                                   analysis of these indicators
                                                                                                                                   to underpin the
                                                                                                                                   performance
                                                                                                                                   management.

Infection Prevention Review HCAI Commissioning Melanie                              March 2008      Updated plan                    The Plan has been
and Control          plan and update to include all Sirotkin                                                                        updated and submitted to
                     relevant       recommendations                                                                                 Clinical Risk Management
                     from      the     provider and                                                                                 Task Group September
                     commissioner review of the                                                                                     2008.
                     management of cases of
                     C.Difficile at Shire Hill.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            11
   Development/                  Key Aim/Objective                    Lead          Target Date        Performance Measure                Reported Progress
      Topic                                                         Person(s)
                           Ensure all service specifications      Melanie           April 2008      Specifications reviewed and Completed, and on a
                           state the requirements for clear       Sirotkin/                         updated.                    rolling programme as
                           record keeping in patients‟            Anne                                                          specifications are
                           case notes by all professional         Rothery                                                       renewed.
                           groups.

CAS/MDAs                   Review and agree local Heather                           By July 2008    Robust local procedures for       CAS alerts now received
                           procedures to ensure a robust Palmer                                     dissemination of alerts, which    via new web-based
                           system for responding to and                                             includes a tracking system to     system. Alerts filtered by
                           actioning alerts within specified                                        ensure receipt of alerts and      Director of Clinical
                           deadlines.                                                               identification of responses.      Standards and only
                                                                                                                                      disseminated as
                                                                                                                                      appropriate.
                                                                                                                                      Tracking system in place
                                                                                                                                      for receipt of responses.
                                                                                                                                      Robust dissemination
                                                                                                                                      process now in place
                                                                                                                                      within Provider Directorate.

Extending     role   of    Ensure all clinical imaging            Jayne             September       ANPs      comply      with     joint Project initiated by target
Advanced          Nurse    requests from non-medically            Southworth/       2008            professional eligibility criteria    date.
Practitioners         in   qualified professionals working        Nikki Leach                                                            Evaluation report March
Primary            Care    in Primary Care are accepted           (PCT)                             Clinical imaging referral            2009.
(Delivering the NHS        by Clinical Imaging dept in                                              process and IR(MER) training
Plan 2002. Liberating      secondary care                         Dr Ian Brett/                     completed
the talents)                                                      Paul Fish
                                                                  (NHS                              Referrals carried out and         Reports to Board via
                                                                  Foundation                        accepted                          Provider     Healthcare
                                                                  Trust)                                                              Governance Committee.
                                                                                                    Audit standards agreed

                                                                                                    Audit/evaluation carried out.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                12
     Development/               Key Aim/Objective                    Lead           Target Date       Performance Measure            Reported Progress
        Topic                                                      Person(s)
Clinical       Quality Assure PCT commissioners of Anne Rothery                     Monthly         Key Performance Indicators Quarterly   reporting     to
Reviews of Acute       the quality of Acute Trust                                   meetings        as per Acute Trust contract Board    via       Clinical
Trust contract         provision.                                                                                               Governance            Sub-
                                                                                                                                Committee.
Clinical       Quality Assure PCT commissioners of Heather                          Monthly         Key Performance Indicators Regular verbal updates
Reviews of Mental quality of Mental Health Trust Harrisson                          meetings        as per contract             given but minutes from
Health Trust contract  provision.                                                                                               Pennine    Care   Quality
                                                                                                                                Group to be shared at
                                                                                                                                Performance    Monitoring
                                                                                                                                Group     and     Clinical
                                                                                                                                Governance           Sub-
                                                                                                                                Committee.
                                                                                                                                Quarterly schedule for
                                                                                                                                2009/10 agreed.
NPSA        Medication Implement new guidance Anne Rothery/                         As issued       KPI‟s as per each guidance. Reports   to    Medicines
Reviews                as appropriate.        Peter Howarth                                                                     Management Committee
                                                                                                                                as    appropriate     and
                                                                                                                                relevant.
Provision            of
appropriate training
to    maintain    safe
practice, including:

     Child Protection      All staff who work with Kay Worsley-                    Ongoing         Attendance Records.          Quarterly management
                            children   received Child Cox and                       Reviewed                                     reports.
                            Protection                related training              annually in
                                                      specialist                    Autumn

     Infection            All staff receive infection
      Prevention         & prevention control training
      Control




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        13
     Development/               Key Aim/Objective                    Lead           Target Date        Performance Measure          Reported Progress
        Topic                                                      Person(s)
     Safeguarding         All   staff    working   with                                            Management reports.
      vulnerable adults    vulnerable adults receive
                           Safeguarding       vulnerable
                           adults training
                                                                                                                                 Quarterly
     Bespoke        All staff using Medical                                                                                     Management
      Medical Device Devices, receive training                                                                                   Reports
      training

     Basic          Life All staff receive basic life                                              ETD Action Plan.
      Support             support training


     Decontamination All relevant staff receive
                      training in decontamination.



     Manual Handling      All staff receive patient Kay Worsley-                   Ongoing         Annual Staff Survey.         SLA lead for moving and
                           handling or object, Manual Cox and                       Reviewed        Quarterly monitoring data.   handling is John Hanson.
                           Handling training          related training              annually in                                  SLA has been reviewed
                                                      specialist                    Autumn                                       and ETD monitor uptake.
                                                                                                                                 Concerns re poor uptake
                                                                                                                                 highlighted at HR Strategy
                                                                                                                                 Group.

     Risk                 All staff receive             Risk          “                    “                                    Risk management training
      Management           Management training                                                                                   uptake remains
                                                                                                                                 satisfactory.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        14
   Development/                 Key Aim/Objective                    Lead           Target Date        Performance Measure      Reported Progress
      Topic                                                        Person(s)
Controlled        Drug     Implementation of policy by Margaret                     Review          Incident reports         Implemented and
Policy for Community       all staff who administer Hayes                           March 2009                               cascaded to staff.
Nurses       including     controlled   drugs    within                                                                      Naloxone guidance
Clinical Guidelines for    patients‟ home.                                                                                   included.
the administration of
Naloxone




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                   15
Domain Outcome:               Patient Safety is enhanced by the use of healthcare processes, working practices and systematic activities that
                              prevent or reduce the risk of harm to patients

  Development/                 Key Aim/Objective                   Lead            Target Date          Performance Measure               Reported Progress
     Topic                                                       Person(s)
PROVIDER DIVISION

Risk Management           Ensure the risk register is Hilary Garratt/             31 October        Minutes of meetings and 100% Relevant managers
                          constantly updated and John Hanson                      2008              of managers trained in the use trained in the use of the
                          reviewed monthly at Provider                                              of risk register.              risk register. Monthly and
                          Senior Management Team                                                                                   weekly changes minuted.
                          and locality meetings. Red
                          risks to be reviewed weekly
                          by Provider Board Senior
                          Management Team.

                          Report progress in relation to      Hilary Garratt/     31 October        Track reduction on risks through All risks recorded on
                          high risks to Provider Senior       John Hanson         2008              the audit trail. Ensure all risks are Performance Accelerator
                          Management Team on a                                                      on Performance Accelerator.
                          weekly basis and in relation
                          to all risks on a monthly basis.
                          Report progress to the PCT‟s        Hilary Garratt/     31 October        Provide      evidence       that   Risks reported via
                          Governance Sub-Committee            John Hanson         2008              Performance Accelerator is in      Provider Division
                                                                                                    use. Demonstrate attendance        Healthcare Governance
                                                                                                    at meetings and the provision of   Committee, through to
                                                                                                    effective reports.                 Provider Board.

                          Provide assurance to the PCT Hilary Garratt/            31 October        A       divisional     assurance Assurance Framework to
                          through      a      divisional John Hanson              2008              framework         that    clearly be completed following
                          assurance framework that                                                  demonstrates how risks are approval of the 2009-12
                          links to and supports the                                                 controlled against high level Business Plan.
                          achievement of the PCT‟s                                                  objectives.
                          corporate objectives.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             16
  Development/                 Key Aim/Objective                   Lead            Target Date          Performance Measure                   Reported Progress
     Topic                                                       Person(s)
Health & Safety           Identify areas of concern Hilary Garratt                31 March          Action Plans      for   areas     of High risks are identified
                          through the risk register and /AD Group                 2008              concern.                             and actioned. Red risks
                          incident log.                                                                                                  reported through
                                                                                                                                         Executive Team.


Incident Reporting        Work with the Trust‟s Risk Hilary Garratt               31 October        Compliance with the Trust‟s Training matrix in place
                          Manager to further develop /John Hanson                 2008              policy and ensure regular across Directorate to
                          the formulation of action                                                 training sessions in this policy. highlight risk
                          plans and regularly monitor                                                                                 management as
                          progress of these plans.                                                                                    mandatory training

Infection, Prevention Maintain high standards of Hilary Garratt                   March 2009        Positive results from the PEAT visit   MRSA and C.Diff
& Control             cleanliness  of   inpatient                                                   and achieving the performance          performance indicators
                      facilities.                                                                   indicators in relation to MRSA         achieved.
                                                                                                    and C.Diff.                            Robust cleanliness
                                                                                                                                           monitoring systems in
                                                                                                                                           revised draft SLA‟s.
                                                                                                                                           Awaiting HCC Hygiene
                                                                                                                                           Code report.

                          Regularly report and monitor Hilary Garratt             Ongoing           Report   regularly to  Senior          Regular reports to Senior
                          the incidence of healthcare                                               Management Team, Provider              Management Team.
                          acquired infections (HCAIs).                                              Board, Healthcare Governance           Also discussed at PCT
                                                                                                    Committee      and    Clinical         Clinical Risk
                                                                                                    Governance Sub-Committee.              Management Task
                                                                                                                                           Group, as appropriate.

                          Implement Health Acts 2006: Hilary Garratt              Ongoing           Regular positive audit results.        Audit programme in
                          Code of Practice for the                                                                                         progress , Actions taken
                          Prevention and Control of                                                                                        as per results.
                          Health      Care   Acquired
                          Infections (HCAIs)



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                    17
  Development/                 Key Aim/Objective                   Lead            Target Date          Performance Measure              Reported Progress
     Topic                                                       Person(s)
Child Protection          Ensure the PCT has a Hilary Garratt                     October           In   post    –      leading   on Designated nurse in post
                          Designated Nurse for the                                2008              Safeguarding                     (Kath Fitzgerald)
                          protection and safeguarding
                          of children and young
                          people
                          Ensure that policies are in K Fitzgerald                January           Policies approved                 For review every 2 years.
                          place for all staff and Designated                      2008
                          contractors.                Nurse

                          Ensure     that   mandatory K Fitzgerald                January           PDR                             Audit to be undertaken
                          training in basic awareness                             2008.             Training       Plan          in April 2009. For review
                          and CAF is provided for all                                               place/attendance at training    2010.
                          staff and contractors.

                          Work in partnership with all K Fitzgerald               Ongoing           Member of the Tameside and        In place.
                          agencies and the voluntary                                                Derbyshire       Safeguarding     Designated Nurse now a
                          sector to implement child                                                 Children Boards and their         member of the Tameside
                          protection arrangements in                                                relevant working groups –         and Derbyshire
                          line with NSF for Children,                                               attendance                        Safeguarding Children
                          Young People and Maternity                                                Chair of the Tameside Policy      Boards and attends
                          Services    (Standard     5                                               and Procedures Group.             regular meetings.
                          Safeguarding and Promoting
                          the Welfare of Children and
                          Young People)

                          Implement the new Child K Fitzgerald                    Summer            Staff trained and the database Practice     database
                          Protection Module for Child                             2008              evaluated.                     implemented.
                          Health

                          Provide    Child    Protection K Fitzgerald             February          Audit                             Audit questionnaire sent
                          Supervision for appropriate                             2007                                                out to practitioners for
                          practitioners every 4 months.                                                                               evaluation March 2008.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            18
  Development/                 Key Aim/Objective                   Lead            Target Date          Performance Measure               Reported Progress
     Topic                                                       Person(s)
Child Protection          Produce an Annual Board K Fitzgerald                    Summer            Report produced/Acceptance Completed in August
(cont/d)                  Report                                                  2008              by the Board                       2008 and submitted to
                                                                                                                                       Board in September 2008,
Waste Management          Complete training of staff on Chris Ryan                June 2008         Training delivered.                Training room and trainer
                          „Site Waste Management‟                                                                                      booked for May 2009.
                          manual.                                                                                                      All training completed in
                                                                                                                                       2008.
                          Undertake a full audit of Chris Ryan                    March/April       Audit report complete, actions Independent             Auditor
                          waste          management                               2009              identified, funding identified and appointed to carry out
                          processes/systems      to                                                 approved.                          Audit, to be undertaken
                          determine success of the                                                                                     in March 2009 with report
                          implementation    of new                                                                                     available in April 2009.
                          strategy.

                          Implement             any Chris Ryan                    March 2009        Project plan determined and Dependant on above
                          changes/actions                                                           undertaken.
                          recommended in the audit
                          (subject to funding).

Decontamination           Set    up       Maintenance Chris Ryan                  June 2008         Contract in place.             All contracts in place,
(Dental Surgeries)        Contract for Autoclaves and                                                                              funding       to     cover
                          washer disinfections                                                                                     maintenance of Washer
                                                                                                                                   Disinfectors not yet fully
                                                                                                                                   identified.
Fire                      Ensure that all premises are Chris Ryan                 Regular           Fire Safety Adviser to confirm Fire     Safety     Adviser
Compartmentation          kept up to relevant standard.                           reviews           compliancy as part of annual annually       audits    and
                                                                                  throughout        risk assessment process.       inspects Trust premises,
                                                                                  the year                                         and produces a Fire Risk
                                                                                  required                                         Assessment report, which
                                                                                                                                   is submitted to both the
                                                                                                                                   H&S Committee and T&G
                                                                                                                                   Fire     Safety     Liaison
                                                                                                                                   Committee.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                              19
Second Domain – Clinical and Cost Effectiveness


Domain Outcome:                Patients achieve health care benefits that meet their individual needs through healthcare decisions and
                               services based on what assessed research evidence has shown provides effective clinical outcomes


     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure         Reported Progress
        Topic
COMMISSIONING
DIVISION

National  Institute    for     Health development and Claire Watson/                       September     Protocol    for  Service Protocol developed and
Clinical     Excellence        care     pathway      design Alison Leigh                   2008          Redesign in place.       signed off by PEC in
(NICE)                         protocols to include review                                                                        December 2008.
National          Service      and    implementation     of
Framework (NSFs)               appropriate NICE guidance
                               and NSF requirements.

                               Ensure    an      integrated Heather Palmer                 April 2008    Robust      processes Discussions    ongoing    re
                               approach        to       the                                Onwards`      established      and establishment         of    a
                               implementation, monitoring                                                communicated.         NICE/National Guidance
                               and formalising of NICE                                                                         Task     Group,     for the
                               guidance in order to be able                                                                    implementation/monitoring
                               to demonstrate adherence.                                                                       of all NICE guidance.
                                                                                                                               NICE guidance also now a
                                                                                                                               standing        item     on
                                                                                                                               Medicines     Management
                                                                                                                               Committee and LTC/CAG
                                                                                                                               meetings.

                               Achievement of the            NSF Anne Rothery/             March 2009    Services commissioned Performance   indicators
                               framework for CHD                 Lee Hawksworth                          via pathway.          implemented via Long
                                                                                                                               Term         Conditions
                                                                                                                               Group/CHD Group.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        20
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date    Performance Measure            Reported Progress
        Topic
                               Ensure that all medicines Dr J Doldon/                      Ongoing        Medicine    aspects of      System in place.
                               related NICE guidance is Peter Howarth                      during         NICE    guidance      are   Appropriate/relevant NICE
                               implemented and monitored                                   2008/09        discussed   and    issues   guidance discussed and
                               by      the     Medicines                                                  around implementation       NICE        Bites      now
                               Management Committee.                                                      considered.                 disseminated to practices.

Research Governance/           Review     the    operational Heather Harrisson             By July 2008   Operational group      TOR reviewed and agreed
Evidence Based Practice        aspects of the CE/R&D Group                                                structure revised and by Task Group, March
                               (linking    with    Regional                                               new Terms of Reference 2009.
                               Research Networks).                                                        agreed.

                               Develop an R&D Strategy to Heather Harrisson                By July 2008   Strategy developed and R&D Strategy deferred in
                               include research governance                                                widely circulated.     view of Clinical
                               function.                                                                                         Governance Task Group
                                                                                                                                 restructure. Strategy for
                                                                                                                                 discussion and
                                                                                                                                 development by July 2009
                                                                                                                                 by R&D Task Group.

                               Ensure evidence and quality Claire Watson/                  Ongoing        Scoring systems in place.   Prioritisation process
                               are part of the Operational Melanie Sirotkin                during                                     agreed at PEC in January
                               Plan scoring system and                                     2008-09                                    2009 and Board in February
                               decision making process.                                                                               2009.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            21
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure            Reported Progress
        Topic
                               All needs assessment and Sabrina Fuller                     Ongoing       Production of Needs Joint Strategic Needs
                               equity audits to include                                    during        Assessments and Equity Assessment (in partnership
                               sections  on     addressing                                 2008-09       Audits.                with TMBC) completed
                               evidence based practice.                                                                         and went to both the
                                                                                                                                Health Partnership Board
                                                                                                                                and Strategic Partnership
                                                                                                                                Board in February 2009
                                                                                                                                Teenage Pregnancy Needs
                                                                                                                                Assessment completed
                                                                                                                                and went to Executive
                                                                                                                                Board in January 2009.
                                                                                                                                Waiting to go to
                                                                                                                                Derbyshire.
                                                                                                                                Chlamydia Screening
                                                                                                                                Equity Audit completed
                                                                                                                                March 2009.

                                                                                                                                    Others currently
                                                                                                                                    underway:- Sexual Health,
                                                                                                                                    Tobacco Control, Review
                                                                                                                                    of Mental Health, and
                                                                                                                                    CVD.

Clinical      Audit/Quality Support the Acute Trust on Anne Rothery                        Ongoing       Evidence of robust audit   Clinical Governance
initiatives                 audit of clinical work to be                                   during        activity within agreed     Manager now a member
                            assigned to quality measures                                   2008-09       contracts.                 of the Acute Trust Clinical
                            within agreed contracts.                                                     Robust    clinical audit   Audit/Effectiveness
                                                                                                         plan.                      Committees – areas for
                                                                                                                                    Interface Audit to be
                                                                                                                                    discussed and agreed.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            22
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure            Reported Progress
        Topic
Clinical      Audit/Quality Review    the   operational Heather Harrisson                  By June       Operational        group TOR reviewed and agreed
initiatives (cont/d)        aspects   of  the  Clinical                                    2008          structure reviewed and by Task Group March 2009.
                            Audit/Quality Improvement                                                    Terms    of    Reference
                            Group.                                                                       agreed.

                               Develop PCT provider Clinical Lynda Lowe/                   Ongoing       Annual Clinical Audit      Clinical Audit Action Plan
                               Audit capacity and action Clinical Audit                    during        Plan     linked  to  PCT   produced in September
                               plan.                         Lead                          2008-09       Clinical      Governance   2008. Out-turn report
                                                                                                         Plan and Strategy.         produced March 2009.
                                                                                                                                    Production of Clinical Audit
                                                                                                                                    Strategy 2008/09 deferred
                                                                                                                                    in view of Task Group
                                                                                                                                    restructuring.

                               Support the implementation Lynda Lowe/                      Ongoing       Clinical  Audit        that Various meetings have
                               of a Clinical Audit plan within Clinical Audit              during        demonstrably links to PCT taken place with LSCs and
                               the Provider Division.          Lead                        2008-09       and national priorities.    HCG Facilitator re Clinical
                                                                                                                                     Audit Process and Clinical
                                                                                                                                     Audit Calendars.
                                                                                                                                     Clinical Governance
                                                                                                                                     Manager member of the
                                                                                                                                     new Provider Division
                                                                                                                                     Healthcare Audit Group –
                                                                                                                                     first meeting held
                                                                                                                                     November 2008.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            23
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure            Reported Progress
        Topic
Clinical      Audit/Quality Support          independent Lynda Lowe                        Ongoing       Programme of clinical      Community Pharmacists
initiatives (cont/d).       contractors in clinical audit                                  throughout    audits planned, aligned    Two Audit Assistants
                            2008/09,    including    SEA,                                  2008-09       to PCT Clinical Audit      packages launched May
                            Enhanced Services Audit,                                                     Strategy and agreed        and September 2008.
                            and align audit plans to PCT                                                 priorities. Training  to   Osteoporosis and
                            priorities.                                                                  support Clinical Audit     Dispensing Process Audits.
                                                                                                         provided as appropriate.   49/51 (96%) of participants
                                                                                                                                    in the Audit Assistant
                                                                                                                                    scheme.
                                                                                                                                    One Community Pharmacy
                                                                                                                                    PCT-wide Audit of COPD
                                                                                                                                    launched January 2009.

                                                                                                                                    Dental Practices
                                                                                                                                    Dental Audit Package
                                                                                                                                    launched October 2008,
                                                                                                                                    covering audits around
                                                                                                                                    Child Protection,
                                                                                                                                    Healthcare Waste
                                                                                                                                    Management and NICE
                                                                                                                                    Recall Intervals.
                                                                                                                                    18/28 (64%) Dental
                                                                                                                                    practices participating in
                                                                                                                                    the scheme.

                                                                                                                                    It is hoped to extend this
                                                                                                                                    scheme into Optometry.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            24
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure         Reported Progress
        Topic
Clinical      Audit/Quality                                                                                                       General Practice
initiatives (cont/d).                                                                                                             Enhanced Services Audit
                                                                                                                                  Package produced
                                                                                                                                  October 2008 and
                                                                                                                                  circulated to all GP
                                                                                                                                  Practices. 38/39 received
                                                                                                                                  by 31/3/09. 38 practices
                                                                                                                                  have completed 134
                                                                                                                                  audits with 27 still
                                                                                                                                  outstanding. Performance
                                                                                                                                  measures to be reviewed
                                                                                                                                  and amended by Dr
                                                                                                                                  Bircher by 31/3/09.

                               Work with Acute Trust to Anne Rothery                       Ongoing       AQ framework agreed.     Work around Advancing
                               ensure high performance in                                  from                                   Quality ongoing. Medical
                               Advancing    Quality  and                                   September                              Director and Associate
                               compliance with NICE.                                       2008                                   Director, Clinical
                                                                                                                                  Governance, members of
                                                                                                                                  the Advancing Quality
                                                                                                                                  Steering Group.

                               Develop          continuous Heather Harrisson               Ongoing       Joint team and meetings Data collection now in
                               measurement systems for                                     throughout    agreed.                 process.
                               Advancing    Quality   and                                  2008-09
                               consistent  recording    of
                               performance 2008/09.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         25
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure                Reported Progress
        Topic
Working with        Partner Re-establish Joint  Adult John Hazelhurst                      Ongoing       Terms    of  Reference,         Joint Governance (Adults)
Organisations               Commissioning Governance                                                     programme of meetings,          is maintained through Joint
                            framework                                                                    minutes and actions.            Commissioning Executive
                                                                                                         Minutes sent to PEC for         Board (JCEB).
                                                                                                         information.

                               Develop the commissioning John Hazelhurst                   Ongoing       3rd Sector commissioning        The        Adults      Joint
                               protocols, which allow third                                              protocols      in     place.    Commissioning Executive
                               sector organisations to play                                              Identification             of   Board      oversees     the
                               an increased role in the                                                  commissioning        activity   commissioning focus for
                               delivery of health and social                                             completed        with    the    Adult Partnership working
                               care provision.                                                           delivery compatibility of       and decides on priorities
                                                                                                         3rd sector organisation.        across    the    range    of
                                                                                                                                         services.    Providing    a
                                                                                                                                         coherent framework for
                                                                                                                                         making decisions which
                                                                                                                                         may arise.

                               Provision of clinical advice to Anne Rothery                As required   Evidence -based Service Available     via contract
                               commissioners‟ during service                                             Specifications   include Data base (Conquest)
                               specification drafts.                                                     Quality Standards.       Clinical Governance input
                                                                                                                                  into       all    Service
                                                                                                                                  Specifications.

Clinical Care/Skills           Improve the rate of annual Kay Worsley-Cox/                 December      Improvement monitored 2007 results – 50%
                               appraisal and PDP to 60%. Directorate Leads                 2008          through the staff opinion Investors    in     People
                               Development across the PCT.                                               survey.                   recognition January 2009.
                                                                                                                                   Measurable improvement
                                                                                                                                   in quality of PDPs and
                                                                                                                                   process.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                26
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date   Performance Measure              Reported Progress
        Topic
Clinical       Guidelines, Develop        a       Clinical Heather                         April 2008    Terms of Reference and       CGSC acting as surrogate
Policies & Protocols       Guidelines/Policies/Protocols   Harrisson/Alan                  onwards       membership         clearly   membership with ToR
                           Group      to     ensure     a Dow                                            identified.                  drafted and under
                           standardised approach to                                                      Robust database of all       discussion. For further
                           dissemination,                                                                guidelines in place.         discussion at Clinical
                           implementation             and                                                                             Governance Sub-
                           monitoring      of     clinical                                                                            Committee, April 2009.
                           guidelines    and    protocols                                                                             Database implemented
                           across the PCT and other                                                                                   and monitored by
                           providers of health and social                                                                             Guidelines Implementation
                           care.                                                                                                      Manager.

                               Ensure that clinical audit is Heather Palmer/               Ongoing       Programme of clinical        Clinical guidelines now
                               part of the review process for Lynda Lowe                   during        audit implemented as         reviewed and fed into
                               all clinical guidelines.                                    2008-09       part of the PCT Clinical     audit cycle.
                                                                                                         Audit Plan.                  Audit of Anti-Coagulant
                                                                                                                                      Monitoring (NPSA 18)
                                                                                                                                      included as part of the
                                                                                                                                      Enhanced Services Audit
                                                                                                                                      Package for 2008-09.

                                                                                                                                      Audit of compliance of
                                                                                                                                      NICE Guidance in relation
                                                                                                                                      to Recall intervals included
                                                                                                                                      in Dental Audit Assistant
                                                                                                                                      Package (October 2008).
                                                                                                                                      In line with NPSA 2008/PSA
                                                                                                                                      001”Clean Hands Save
                                                                                                                                      Lives” a Hand Hygiene
                                                                                                                                      Audit was carried out in 23
                                                                                                                                      General Practices and 6
                                                                                                                                      clinics. Awaiting results.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             27
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date    Performance Measure            Reported Progress
        Topic
Support               the Support C & P in developing Louise Roberts                       Draft, end of In     line  with    the Two Away Days held. One
development of a robust a project plan including ideas                                     May 2008      Operational Plan for the was attended by all C&P
Business Plan for C&P     for strategic growth, as                                                       PCT.                     Directorate, to update on
                          identified in the business plan.                                                                        the Vision Values and
                                                                                                                                  Behaviours objective that
                                                                                                                                  links into the PCT‟s Strategic
                                                                                                                                  Operational Plan. The
                                                                                                                                  second was attended by
                                                                                                                                  C&P Team, to look at
                                                                                                                                  possible restructure; which,
                                                                                                                                  as a result, was
                                                                                                                                  implemented.
Assist   in  monitoring Support C & P in developing Louise Roberts                         June 2008     Implementation        of Tender/Non-Tender RAG
progress         when PRINCE         II     project                                                      project     management rated and updated on
commissioning           management methodology.                                                          tools.                   Performance Accelerator
evidence-based
services working with
Public Health & Health
Strategy

Support       in      the Ensure Project Management Louise Roberts                         June 2008     Implementation   of Performance Accelerator
development of a robust support for all projects.                                                        project  management in use by all Directorates to
commissioning,                                                                                           tools.              monitor performance of
procurement,                                                                                                                 projects.
performance monitoring
and           contracting
process, linking into the
project     management
process

Management             and Develop intelligence systems Ben Dearden                        05/05/08      Reports    available   to   Business Intelligence to
reporting      of  clinical to support management of                                                     compare clinical quality    liaise with Medical
quality intelligence        clinical quality indicators                                                  indicators to contracted    Directorate Officers to
                                                                                                         standards                   define business needs.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                               28
     Development/                   Key Aim/Objective                Lead Person(s)        Target Date    Performance Measure               Reported Progress
        Topic
Patient Experience/            Develop intelligence systems Ben Dearden                    31/07/08       Agreed      protocols    in   Will form part of metric
Satisfaction Intelligence      to support management of                                                   place     for     capture,    development for WCC
                               patient experience/                                                        management             and    Competency 3. Will also
                               satisfaction indicators                                                    reporting      of   patient   be picked up as part of
                                                                                                          experience/satisfaction       delivery of Public
                                                                                                          and value indicators          Experience strategy.
Continuing Professional All staff employed in the Hilary May                               April 2008     Staff        performance      This is an ongoing process
and           Personal Assessment      Booking    and                                                     monitored          through    with revision of content of
Development/Training    Choice Centre will receive a                                                      monthly               audit   training programme after
                        2-week competency based                                                           mechanism           against   each evaluation.
                        induction    programme      to                                                    objectives of service and
                        enable them to carry out                                                          service KPI‟s.
                        their role and function to the
                        required standard

Communication/working          Assessment, Booking and Hilary May                          Ongoing        Following Connecting for Current systems in place
with health and social         Choice Centre to act as the                                 process with   Health guidelines and are ensuring this category
care     and   partner         interface between GP‟s and                                  yearly         Department of Health is met in full.
organisations                  service providers and any                                   reviews        Best Practice
                               associated               partner
                               organisation to ensure that
                               patient        referrals     are
                               managed in a timely and
                               clinically safe environment.
Clinical Effectiveness         Assessment, Booking and Hilary May                          Ongoing        Following DH                  No updates to add at this
                               Choice Centre to deliver the                                service        Gateway reference 8705        time.
                               Transport Booking Service                                   review
                               based on a clear eligibility
                               criteria laid down by the DH
                               to ensure effective use of
                               transport resources, clinically
                               appropriate to patient needs.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                29
Second Domain – Clinical and Cost Effectiveness

Domain Outcome:                Patients achieve health care benefits that meet their individual needs through healthcare decisions and
                               services based on what assessed research evidence has shown provides effective clinical outcomes


   Development/                Key Aim/Objective                   Lead           Target Date          Performance Measure               Reported Progress
      Topic                                                      Person(s)
PROVIDER DIVISION

Health Improvement         Obesity – reduce childhood Hilary Garratt/             March 2009        Measurements                       Obesity Strategy Lead –
                           obesity by establishing a Judith Grigg                                   October 2008 to hit         the     Sabrina Fuller
                           baseline in 08/09.                                                       mandatory 85% target.            National Child
                                                                                                                                        Measurement
                                                                                                                                        Programme targets
                                                                                                                                        achieved 2008/09
                                                                                                                                    Work ongoing for
                                                                                                                                    childhood obesity
                                                                                                                                    pathways
                   „Quitting   Smoking‟   –                   Hilary Garratt/     March 2009        National target attained.
                   increase the number of                     Kathy Powys
                   quitters.
NICE      Guidance Further   develop    and                   Hilary Garratt/     March 2009        Reports to HGC and audit Process for NICE
Implementation     implement action plans                     John Hanson                           results.                 compliance in
                   based on disseminated                                                                                     development which will
                   NICE guidance.                                                                                            feed into and inform PCT
                                                                                                                             wide approach.
Service Reviews            Completion of the LEAN Hilary Garratt/                 March 2009        Implementation   of LEAN LEAN      recommendations
                           Service Review for the AD group                                          recommendations.         being implemented across
                           priority     areas       e.g.                                                                     the relevant groups and
                           wheelchair,         dietetics,                                                                    LEAN reviews undertaken in
                           podiatry,       intermediate                                                                      the     Transfer     Service,
                           care, transfer team.                                                                              Wheelchair           Service,
                                                                                                                             Podiatry and Shire Hill
                                                                                                                             Intensive Care Unit.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            30
    Development                Key Aim/Objective                   Lead           Target Date          Performance Measure                 Reported Progress
       /Topic                                                    Person(s)
Healthcare Audit           Develop    PCT    Provider John Hanson                 By June 2008      Annual audit calendar for          Healthcare Audit group
                           Division                                                                 Provider Division to relate to     meeting monthly, terms of
                           Healthcare Audit capacity                                                areas of risk and priorities       reference agreed by
                           and action plan.                                                         identified in the business plan.   Health Care Governance
                                                                                                                                       Committee.
                                                                                                                                       Associate Directors sign off
                                                                                                                                       of all healthcare audits
                                                                                                                                       within Provider Division,
                                                                                                                                       prior to submission to PCT
                                                                                                                                       Clinical Audit Chair for final
                                                                                                                                       approval and sign off.

                           Implement Provider Division John Hanson                Ongoing                                              All audit activity now being
                           Healthcare    Audit     Plan                           during                                               inputted onto Performance
                           linked to PCT Clinical Audit                           2008/09                                              Accelerator. Reports
                           Strategy and Plan.                                                                                          generated for Healthcare
                                                                                                                                       Governance.

Essence of Care            Continue to roll out the John Hanson/                  Ongoing           Develop an annual            Essence of Care now
                           Essence        of     Care Marion Gilchrist            during            programme for the Essence of incorporated into the
                           Benchmarking Tool across                               2008/09           Care.                        Healthcare Audit group
                           all clinical teams, with a                                                                            (includes PCT Clinical
                           continued programme of                                                   Evidence        of continual Governance Manager as a
                           protocol      benchmarking                                               improvement as a result of member of the group).
                           during 2008-09, to allow                                                 audit activity.              Benchmarking with Greater
                           movement           towards                                                                            Manchester continues .
                           external benchmarking in
                           subsequent years.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                 31
    Development                Key Aim/Objective                   Lead           Target Date          Performance Measure             Reported Progress
       /Topic                                                    Person(s)
Standards for Better Continue       to     increase           John Hanson/        March 2009        Production of a Standards for Quarterly reports submitted
Health (StfBH)       compliance with StfBH to                 Marion                                Better Health calendar.       to        PCT        Clinical
                     ensure that Provider Division            Gilchrist/                                                          Governance              dept.
                     is in a position to inform the           Performance                                                         Operational management
                     PCT regarding the quality of             and                                                                 service     reviews       are
                     services provided in relation            Development                                                         strengthening             the
                     to the Annual Declaration.               Unit                                                                compliance with StfBH.
                                                                                                                                  Operationally,        service
                                                                                                                                  review action plans are
                                                                                                                                  inputted onto Performance
                                                                                                                                  accelerator
Improving Palliative Specialist Palliative Care Margaret                          September         Annual audit of prescribing 4       Community        Nurse
Care / non-medical Team to be able to Hayes                                       2009              activity.                     Specialists within the team
prescribers          prescribe medication within                                                                                  have undergone the NMP
                     their scope of specialty for                                                                                 course. 1 CNS to enrol by
                     patients with life limiting                                                                                  September 2009.
                     illness.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           32
Third Domain - Governance


Domain Outcome:               Managerial and clinical leadership and accountability, as well as the organisation’s culture, systems and
                              working practices ensure that probity, quality assurance, quality improvement and patient safety are central
                              components of all the activities of the healthcare organisation

  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure         Reported Progress
     Topic                                                                     Person(s)             Date
COMMISSIONING
DIVISION
Integrated                Ensure the PCT Integrated Governance Mark Simon                       30/09/08     Structure,        meetings   Work ongoing to
Governance                structure and schedule of meetings is fully                                        schedule and ToR agreed      ensure     that  the
                          functional, with agreed terms of                                                   and      published,   with   Committee structure
                          reference.                                                                         evidence              that   is fully mapped and
                                                                                                             arrangements are robust.     all committees‟ TOR
                                                                                                                                          follow a standard
                                                                                                                                          template.

                          Map all core standards to supporting Mark Simon                       30/09/08     Inclusion in approved ToR.   All policies across
                          committees in the PCT, and the Provider                                                                         the PCT to follow a
                          and Commissioning Divisions, to ensure                                                                          standard format.
                          there are no gaps in assurance.
                          Finalise Committee structures to support Mark Simon                   30/06/08     Arrangements     approved Policy     templates
                          Integrated Governance Committee.                                                   by Board.                 agreed           and
                                                                                                                                       approved           by
                                                                                                                                       Integrated
                                                                                                                                       Governance
                                                                                                                                       Committee will roll
                                                                                                                                       out from April 2009.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                          33
  Development/                        Key Aim/Objective                          Lead               Target      Performance Measure             Reported Progress
     Topic                                                                     Person(s)             Date
                          Ensure the PCT Clinical Governance Heather                            By July 2008   Structure,        meetings       Achieved. ToR for
                          Committee structure and schedule of Harrisson/Alan                                   schedule and TOR agreed          CGSC ratified by
                          meetings is fully functional with agreed Dow                                         and      published    with       PEC, although
                          new Terms of Reference                                                               evidence              that       subsequent minor
                                                                                                               arrangements are robust          amendments now
                                                                                                                                                made – for final
                                                                                                                                                discussion at CGSC
                                                                                                                                                in May 2009.
                                                                                                                                                Schedule of
                                                                                                                                                meeting dates
                                                                                                                                                arranged.

                          Ensure the PCT Clinical Governance Task Heather                       By July 2008   As above
                          Group structures are fully functional with Harrisson
                          agreed new TOR

Strengthening    the      Ensure that governance arrangements
Clinical Governance       with   independent   contractors are
arrangements      for     strengthened and developed, taking
Independent               account of the different levels of
Contractors               involvement and implementation.

                            Community Pharmacy – further Mary Callan                           Ongoing        Utilising Standards for Better   Round 2: visits
                             development of the monitoring                                                     Health Framework in the          completed (51
                             process for assessing compliance with                                             Pharmacy Visits. Agreed          pharmacies).
                             the    Pharmacy       contract    and                                             criteria for visit schedules     Round 3: visits for
                             Community      Pharmacy     Assurance                                             for Round 3.                     implementation
                             Framework.                                                                                                         2009/10.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                     34
  Development/                        Key Aim/Objective                          Lead                   Target    Performance Measure         Reported Progress
     Topic                                                                     Person(s)                 Date
Strengthening the           General Practice – Embed the values Heather                        Throughout       Practices     undertaking    38/39 submissions
Clinical Governance          and processes of Clinical Governance Harrisson                     the year         Enhanced Services submit     received by end of
arrangements for             into every GP practice, i.e. clinical                                               quarterly SfBH monitoring    March from GPs
Independent                  audit,    SEA,     Clinical    quality                                              documents.                   involved.
Contractors (cont/d)         improvement, etc.

                                - Continue to implement quality Heather                             “            Participation in agreed New Enhanced
                               improvement tools and processes, e.g. Harrisson/                                  clinical audit programmes. Services Audit
                               SfBH                                  Lynda Lowe                                                               package produced
                                                                                                                                              November 2008. 38
                                                                                                                                              practices have
                                                                                                                                              completed 134
                                                                                                                                              audits, with 27
                                                                                                                                              outstanding,
                                                                                                                                              received by 3/3/09.
                            Dental – piloting and implementation Brian        July 2008                         New practice visits to be Traffic Light self-
                             of the new practice visit assessment Durgan/Lynda                                   carried out within three assessment tool
                             process and self-assessment StfBH Lowe                                              year cycle commencing 1st launched at Dental
                             “traffic light” document.                                                           July 2008. Practices to be Postgraduate
                                                                                                                 supplied with traffic light session in January
                                                                                                                 document          for   self 2009, but previously
                                                                                                                 assessment at present.       circulated in August
                                                                                                                                              2008.
                              Optometry – engagement with Charles Wass/                        Throughout       Basic Clinical Governance Work ongoing with
                               community optometrists and Local Steve Mayer/                    the year         Framework      and     Self optometrists to
                               Optometry Committee, to develop Philip Owen                                       Assessment            tool consider the
                               Clinical Governance arrangements                                                  developed.                  development of an
                               for optometrists and staff.                                                                                   Audit Assistant
                                                                                                                                             Scheme for staff.
                                                                                                                                             Meeting to be held
                                                                                                                                             28/04/09 with 3 Task
                                                                                                                                             Group Optometric
                                                                                                                                             representatives.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                              35
  Development/                        Key Aim/Objective                          Lead               Target     Performance Measure           Reported Progress
     Topic                                                                     Person(s)             Date
Strengthening    the      Ensure the development of governance Heather                          Ongoing       Production of KPI‟s       for Extensive work
Clinical Governance       and quality frameworks for inclusion in Harrisson                     throughout    each service area             ongoing and KPIs
arrangements      for     contracts as part of the monitoring                                   2008-09 as                                  developed for
Commissioned              process for services commissioned by the                              appropriate                                 Provider Division and
Services                  PCT.                                                                                                              Nursing Home
                                                                                                                                            contracts.

Strengthening             Strengthen the organisational system to Anne Rothery/                 Ongoing       Adherence       to   Provider CGSC agenda now
Internal/External         identify and collect evidence for all Heather                         throughout    agreed KPIs                   captures this.
monitoring                external regulatory reviews from all Harrisson                        2008-09                                     Provider Division KPIs
arrangements              Stakeholders.                                                                                                     and CQUINS
                                                                                                                                            produced.

                          Establish mechanisms to use the Anne Rothery                          Ongoing       Board Reports                  Ongoing reports
                          intelligence from this system to provide                              throughout                                   submitted to Board,
                          assurance of quality and governance to                                2008-09                                      as appropriate.
                          the Board and demonstrate continuous                                                                               Local Intelligence
                          improvement and lessons learned from                                                                               network meetings
                          mistakes.                                                                                                          held. Quarterly
                                                                                                                                             returns examined by
                                                                                                                                             accountable officer.
                                                                                                                                             Monthly Clinical
                                                                                                                                             Review meetings
                                                                                                                                             held to assess Acute
                                                                                                                                             Trust performance.

                          Develop expertise to manage external Heather                          Ongoing       Visit Reports                  Clinical Review
                          reviews using data collection and actual Harrisson                                                                 Officer posts to go
                          visits.                                                                                                            out for advert
                                                                                                                                             April/May 2009.
                                                                                                                                             Team to undertake
                                                                                                                                             visits as part of
                                                                                                                                             managing external
                                                                                                                                             reviews.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                              36
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure         Reported Progress
     Topic                                                                     Person(s)             Date
Clinical Engagement Work in collaboration with GP practices Heather                             October     Organise 40 QOF visits to     Due to problems
and Communication to support the new QOF indicators of the Harrisson/                           2008     to practices    (Oct‟08     to   with QMAS, the QOF
                    nGMS contract.                          Jayne                               March 2009 Jan‟09)     and     provide    Steering Group
                                                            Somerville                                      support to practices on the   made the decision
                                                                                                            process.                      that only a selection
                                                                                                                                          of practices would
                                                                                                                                          be visited this year.
                                                                                                                                          14 full QOF visits
                                                                                                                                          undertaken, with 3
                                                                                                                                          re-visits scheduled.
                                                                                                                                          All 26 remaining
                                                                                                                                          practices had a visit
                                                                                                                                          with the PCT
                                                                                                                                          Manager to assess
                                                                                                                                          QOF evidence
                                                                                                                                          folders.

                          Performance manage the quality/Clinical           Mark                Ongoing      Quality   Standards    met Currently forms part
                          Governance components of the Out of               Shrimpton/          throughout   within agreed timescales   of the regular
                          Hours contract with Go-To-Doc and                 Heather             2008-09                                 performance review
                          Oldham PCT.                                       Harrisson                                                   meetings supported
                                                                                                                                        by Associate
                                                                                                                                        Director, Clinical
                                                                                                                                        Governance.
                                                                                                                                        Regular update
                                                                                                                                        meetings between
                                                                                                                                        Governance
                                                                                                                                        Manager (Go-To-
                                                                                                                                        Doc), Associate
                                                                                                                                        Director (Tameside)
                                                                                                                                        and Associate
                                                                                                                                        Director (Oldham).



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           37
  Development/                        Key Aim/Objective                          Lead               Target     Performance Measure          Reported Progress
     Topic                                                                     Person(s)             Date
Develop a PID for Develop a PID for PA and a project plan                   Louise Roberts      In progress   Each Directorate to use PA PA Lead in each
Performance                                                                                                   for one project by end of Directorate, who
Accelerator  and                                                                                              May 2008.                  has responsibility for
develop a project                                                                                                                        updating the Risk
plan                                                                                                                                     Register using PA.

Strategic  pathway        Delivery of strategic pathways and Mark                               July 2008     Definition    of   services   Deferred due to
through C&P for new       operational policies that provide for the Shrimpton                                 controlled by C&P and         work prioritisation.
and varied contracts      effective negotiation of contracts and                                              those     passed   through    Currently awaiting
and SLAs                  SLAs to Commissioner and Operational                                                procurement           hubs;   commitment to
                          Plan requirements                                                                   alignment with SFI‟s; clear   funding to deliver in
                                                                                                              process from entry point to   2009/10.
                                                                                                              sign     off  that   meets
                                                                                                              regulation and law

Local              Risk Assessment    of    risk    relating            to Ben Dearden          05/05/08      Creation of risk log to be Risk management
Management              implementation of the BI Strategy                                                     managed by the Business regarding
(Business                                                                                                     Intelligence Steering Group Intelligence/Informa
Intelligence)                                                                                                                             tion availability is
                                                                                                                                          now being picked
                                                                                                                                          up as part of WCC
                                                                                                                                          Assurance
                                                                                                                                          Framework.

Management      and Develop intelligence systems to support Ben Dearden                         05/05/08      Reports     available  to     Performance team
reporting         of performance management systems                                                           compare       performance     and Performance
performance                                                                                                   indicators to targets and     Accelerator team
against established                                                                                           standards.                    jointly working on
standards       and                                                                                                                         this with Associate
targets                                                                                                                                     Director of
                                                                                                                                            Consultancy &
                                                                                                                                            Turnaround.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             38
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure            Reported Progress
     Topic                                                                     Person(s)             Date
Staff Development         Ensure that the organisation has Ben Dearden                          30/04/08     Training and Development        Head of BI post
                          appropriate capability within the core                                             Plan created and being          advertised 27/03/09.
                          Business Intelligence (BI) Team                                                    implemented       for     all   BI re-structure to
                                                                                                             established posts within the    ensure Fit for
                                                                                                             Business Intelligence (BI)      Purpose in line with
                                                                                                             Team.                           WCC.
                                                                                                                                             Appointment of
                                                                                                                                             Interim Integrated
                                                                                                                                             Intelligence Project
                                                                                                                                             Manager.
                                                                                                                                             (James Norris)
PDP/PDRs/KSF              All staff to have a professional Hilary May                           Ongoing     Each staff member will           Each staff member
outlines                  development plan in place where                                       target  for have an updated KSF/PDR          has completed a
                          learning needs are identified and action                              review    6 and plan in their personal       KSF outline, reviews
                          plans set in place to support these needs.                            monthly     record that has regular          takes place on a
                                                                                                            review documentation.            monthly basis as
                                                                                                                                             part of audit 1:1
                                                                                                                                             process and
                                                                                                                                             documented in staff
                                                                                                                                             files. Recent new
                                                                                                                                             starters not yet had
                                                                                                                                             this completed as
                                                                                                                                             still in period of
                                                                                                                                             mentorship.
                                                                                                                                             Learning needs
                                                                                                                                             analysis, work is
                                                                                                                                             currently ongoing as
                                                                                                                                             part of the
                                                                                                                                             professional
                                                                                                                                             development review
                                                                                                                                             of staff. Completed
                                                                                                                                             and part of monthly
                                                                                                                                             process.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             39
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure           Reported Progress
     Topic                                                                     Person(s)             Date
PDP/PDRs/KSF              Undertake    learning    needs    analysis Hilary May                 July 2008    A Learning Needs analysis      Learning needs
outlines (cont/d)         assessment in line with service expansion                                          framework      will   be       analysis
                          and development to ensure staff feel                                               produced that will guide       commenced.
                          adequately prepared for the challenges                                             staff development.             Expected
                          ahead.                                                                                                            completion of work
                                                                                                                                            by March 2009

                          All    staff   to   have      professional Hilary May                 Ongoing     PDP‟s assessed during the Ongoing process
                          development plans in place and every                                  review      monthly 1:1 process.
                          effort made to ensure staff develop in line                           through
                          with personal and business needs.                                     monthly 1:1
                                                                                                process

                          Improve the rate of Review and PDP Kay Worsley-                       December     Improvement     monitored Investors in People
                          development against KSF framework Cox and                             2008         through the staff opinion recognition in 2009
                          across the PCT, to 60%.            Directorate                                     survey. 2007 55%.         demonstrates
                                                             leads                                                                     improved quality in
                                                                                                                                       PDPs.

Equality,      Anti- Staff in the Assessment Booking and Hilary May                             Ongoing      Adherence to selection         Ongoing process.
discrimination and Choice      Centre    are    given    equal                                               and recruitment policies       Selection and
Human         Rights opportunities regardless of race, religion,                                             which       ensure      that   recruitment policies
Legislation     and gender and disability.                                                                   recruitment and selection is   followed.
training                                                                                                     based       on     required
                                                                                                             knowledge and skills for the
                                                                                                             role and shows a diverse
                                                                                                             range of gender, race,
                                                                                                             disability/ability      and
                                                                                                             religion within the working
                                                                                                             environment.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             40
  Development/                        Key Aim/Objective                          Lead               Target     Performance Measure        Reported Progress
     Topic                                                                     Person(s)             Date
Staff Induction           All staff joining the Assessment, Booking Hilary May                  In    place Staff will demonstrate their In place and
                          and Choice Service as Patient Choice                                  and         readiness to undertake ongoing
                          Advisors have a 2-week full time common                               ongoing     their role and be given the
                          induction programme which combines                                                opportunity to feedback
                          practice and theory.                                                              through the formal

                          To be followed by a 2-week period of full                                          feedback process that this
                          supported mentorship.                                                              aim     has   been   met.
                                                                                                             Monitored on a monthly
                                                                                                             basis through audit.

Medicines                 Monitor     Medicines    Management               Peter Howarth       Ongoing     RAG Score against        the Third    evaluation
Management                Committee performance against a range             (supported by       and subject various categories           overdue.       Was
                          of indicators by use of the Medicines             MMC and             to   annual                              considered       at
                          Management Strategy Framework and                 MMT)                review                                   March      meeting.
                          objectives document.                                                                                           Ongoing.

                          Safer management of Controlled Drugs              Peter Welsby        Ongoing      e-PACT quarterly measures PCT          Controlled
                                                                            (supported by                    Accountable Officer and Drugs         Policy    in
                                                                            Local                            Local Intelligence Network place.
                                                                            Intelligence                     activity.
                                                                            Network and                                                 Local     Intelligence
                                                                            Accountable                                                 Network meeting.
                                                                            Officer)                                                    Quarterly
                                                                                                                                        prescribing
                                                                                                                                        measures.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           41
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure          Reported Progress
     Topic                                                                     Person(s)             Date
Information               Ensure    confidentiality        of     clinical
Governance                information:-

                            Full set of policies and procedures Chris Wallace                  July 2008    Approved documentation       Suite of documents
                              covering      information   security,                                                                       authorised and are
                              Caldicott, safe havens etc.                                                                                 all available on PCT
                                                                                                                                          Intranet.

                            All staff appropriately trained.                Chris Wallace      March 2009   Results of    staff audit Benchmark    audit
                                                                                                             demonstrate improvement taking place with
                                                                                                                                       expected
                                                                                                                                       completion by end
                                                                                                                                       of May 2009.

                          Information provided to patients via Chris Wallace                    July 2008    Existence     of   suitable Leaflet exists and
                          leaflets, posters and website.                                                     leaflets and web content.   has been modified,
                                                                                                                                         with a view to
                                                                                                                                         distribution Summer
                                                                                                                                         2009.

                          Annual IG Toolkit submission.                      Chris Wallace      March 2009   Accurate          self-audit 2007-08 completed,
                                                                                                             submitted on time.           2008-09 completed,
                                                                                                                                          and submitted to
                                                                                                                                          Connecting         for
                                                                                                                                          Health March 2009.
                                                                                                                                          (70% - green rating).

                          HC SBH C9 submission                               Chris Wallace      September    Accurate          self-audit Completed           in
                                                                                                2008         submitted on time.           2007/2008.
                                                                                                                                          Implemented
                                                                                                                                          2008/09.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            42
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure              Reported Progress
     Topic                                                                     Person(s)             Date
Information               IT and information systems support and
Management &              enhance quality and safety of patient
Technology                care, choice and service planning:-
                             National Programme for IT systems Colin Cohen                     Ongoing to   Progress assessed against All available systems
                               implementation and utilised in                                   2012         DIP                       are     implemented
                               accordance with the DIP as agreed                                                                       and utilised.
                               with the SHA.
                             Local        information systems are Chris Wallace                Ongoing      Progress assessed against Some systems under
                               implemented where required, and                                               Local IM&T Plan           procurement.
                               fully utilised.                                                                                         "eg: information and
                                                                                                                                       hardware
                                                                                                                                       encryption system"

                            Infrastructure „Fit for Purpose‟.              Clive Bass          Ongoing      Assessed      against  CfH Infrastructure exists
                                                                                                             Infrastructure             and being further
                                                                                                                                 Maturity
                                                                                                             Model      Connecting   fordeveloped.
                                                                                                             Health,     Statement      Statement
                                                                                                                                       of                 of
                                                                                                             Compliance completed.      Compliance
                                                                                                                                        submitted.
                            All staff trained in accordance with Kay                           Ongoing      Results of staff Training Annual TNA to be
                             the relevant IM&T project plans.     Worsley/Cox                                Needs Analysis (TNA) will maintained.
                                                                                                             influence further training
                                                                                                             programmes.

                          Internet presence capable of supporting Chris Wallace                 Summer       Existence       of   „fit    for Revised internet and
                          all public-facing Clinical Governance                                 2008         purpose‟      intranet      and intranet sites now
                          initiatives.                                                                       internet sites.                  live.

                          Intranet facility capable of supporting all Chris Wallace             Summer       As above.                        As above. Clinical
                          staff-facing       Clinical   Governance                              2008                                          Governance site for
                          initiatives.                                                                                                        update and revision,
                                                                                                                                              once all ToR etc. are
                                                                                                                                              fully approved.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                               43
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure          Reported Progress
     Topic                                                                     Person(s)             Date
Clinical               Development of Clinical Advisory Groups Alison Leigh                     May 2008     Advisory group structures    Advisory Groups
engagement         and and governance structures to support                                                  and Terms of Reference in    established for Long
leadership             PEC                                                                                   place. Work programme        Term Conditions:-
                                                                                                             agreed.                      Diabetes, CVD,
                                                                                                                                          Respiratory, Sexual
                                                                                                                                          Health, planned
                                                                                                                                          care (including sub-
                                                                                                                                          groups for
                                                                                                                                          orthopaedics and
                                                                                                                                          dermatology),
                                                                                                                                          urgent care, end of
                                                                                                                                          life/palliative care.

                          Develop PEC Clinical Leads role to                Melanie             Ongoing      PEC leads in place for key Achieved – PEC
                          support commissioning decision making             Sirotkin/                        programmes.                 leads in place for all
                          and     performance     management                Kathryn                                                      key work
                          processes.                                        Magson/                          PEC lead role identified in programmes.
                                                                            Raj Patel                        commissioning processes.

World Class               Support and develop the World Class               Melanie             Throughout   Programme in place to Strategic plan
Commissioning             Commissioning programme to deliver a              Sirotkin/           the year     support 3   new   work identifies key work
                          more strategic and long term approach             KathryMagson                     streams                programmes – 5
                          to commissioning health and care                  /Raj Patel                                              identified – Health
                          services.                                                                                                 Inequalities/Alcohol/
                                                                                                                                    Mental Health/CVD
                                                                                                                                    and a “Healthy Start
                                                                                                                                    in Life for Children”.

Commissioning             Develop Practice-based commissioning Claire                           September    Customer support group Agreeing customer
                          support through “customer support Watson/                             2008         infrastructure in place support
                          group” structures to strengthen practice Louise Rigg                                                       infrastructure with
                          involvement and ensure support is                                                                          identified
                          tailored to practices expressed needs.                                                                     commissioning leads
                                                                                                                                     to support PBC.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           44
  Development/                         Key Aim/Objective                         Lead               Target    Performance Measure           Reported Progress
     Topic                                                                     Person(s)             Date
Working with Partner Re-establish  Joint  Commissioning John                                    May 2008     Terms     of    Reference,     Joint Governance
Organisations        Governance Framework with an adult Hazelhurst                                           programme of meetings,         (Adults) is
                     focus                                                                                   minutes     and    actions.    maintained through
                                                                                                             Minutes sent to PEC for        Joint Commissioning
                                                                                                             information.                   Executive Board
                                                                                                                                            (JCEB).

Effective use        of Introduction of revised structure and Gideon Smith/ October                          Staff    appointed,    new Staff appointed and
Resources                 processes.                                        Michelle            2008         structure   and     process new process
                                                                            Rothwell                         adopted by PEC.             adopted by PEC.
                                                                                                                                         First Policy Group
                                                                                                                                         meeting planned for
                                                                                                                                         March 2009.

Screening                 Development of Screening Governance Gideon Smith                      September    Framework in place.            Commitment
                          Framework with partner agencies.                                      2008                                        achieved from
                                                                                                                                            relevant Tameside
                                                                                                                                            Hospital Foundation
                                                                                                                                            Trust departments.
                                                                                                                                            Draft Framework for
                                                                                                                                            discussion at next
                                                                                                                                            Maternity Services
                                                                                                                                            Liaison Committee
                                                                                                                                            and Screening
                                                                                                                                            Group meetings.

Staff Induction           Review the contents of the staff induction Kay Worsley-               Autumn       Attendance recorded -          Induction reviewed.
                          programme.                                 Cox                        2008         monitoring      number    of   Now       incorporates
                                                                                                             people           undertaking   essential mandatory
                                                                                                             mandatory training in the      training.        Local
                                                                                                             first 12 months in post.       induction     to   be
                                                                                                                                            strengthened during
                                                                                                                                            2009.



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             45
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure         Reported Progress
     Topic                                                                     Person(s)             Date
Education, Training Review and evaluate ETD opportunities to Kay Worsley-                       Annual       Staff opinion survey         Annual   process    in
and    Development meet      corporate    and     personal Cox                                  review       World Class HR               place.
opportunities       requirements by December 2008.                                                           WCC assessment

Contracts                 Production of procedure notes, in Elaine                              October      Electronic procedure notes 45% complete. Will
Management                Contracts    Management      to ensure Simpson                        2008         available                  be 100% complete
(procedure notes)         equity/continuity    in   oversight    of                                                                     by end of June
                          independent      contractors   regulatory                                                                     2009.
                          frameworks.

Patient     Services Production of procedure notes, to ensure               Karen Smith         October      Electronic procedure notes   25% complete
(procedure notes)    quality, clarity and continuity with patient                               2008         available
                     records domain.

Communication/            Ensure      effective    two       way Margaret                       May 2008     Completed                    Strategy for internal
Working with Health       communications are in place with health Hyde                                       communications strategy      and         external
and Social Care and       and     social   care   and     partner                                            signed off by the Board      communications
Partner                   organisations.                                                                     and published.               currently          in
Organisations.                                                                                                                            production. To go
                                                                                                                                          to Board in May
                                                                                                                                          2009.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            46
  Development/                        Key Aim/Objective                          Lead               Target      Performance Measure           Reported Progress
     Topic                                                                     Person(s)             Date
Developing        the Ensure an appropriately constituted
Workforce / Lifelong workforce with appropriate skill mix across
Learning              the community:

                                 Implement Improving          Working Joanne                   (IWL)    April HR            Performance      PCT continues to
                                  Lives (IWL) initiatives and move Marshall                     2006           framework                      support     the    IWL
                                  towards     adoption       of    the                          onwards        HR Strategy Group              ethos    and      work
                                  Corporate         Citizenship      –                                         New        HR       Strategy   continues     on    all
                                  Employment and Skills standards,                              (Corporate     document                       strands listed, with
                                  which    collectively     contribute                          Citizenship) New Workforce Strategy           regular reports to HR
                                  towards „Model Employer‟ status.                              April 2008     document                       Strategy Group and
                                                                                                onwards        New          Organisational    Board – ongoing.
                                                                                                               Development Leadership,        Re-obtained
                                                                                                               Management and Business        Investors in People in
                                                                                                               Strategy document              January      2009    in
                                                                                                               Workforce        informatics   support of this ethos.
                                                                                                               available for Directorates,
                                                                                                               HR Strategy Committee
                                                                                                               and Trust Board (May 2008)
                                                                                                               Annual     Staff    Opinion
                                                                                                               Survey.

                          Benefits Realisation from Agenda for Joanne                           April 2008    Reduced/resolved number         Agenda for Change
                          Change                               Marshall                         Onwards       of appeals                      now mainstreamed
                                                                                                              Number of panels                and regular panels
                                                                                                              Mainstreamed A4C panels         set up. No backlog
                                                                                                              Review of services              exists or unresolved
                                                                                                              /directorate configurations     appeals,         but
                                                                                                              embedded.                       process ongoing.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                47
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure            Reported Progress
     Topic                                                                     Person(s)             Date
Developing the            Review the PCT‟s Equal Opportunities Joanne                           September    Policy reviewed through         Programme            of
Workforce / Lifelong      Policy and Procedures.               Marshall                         2008         the Policy Development          review for all policies
Learning (Cont’d.)                                                                                           Group. Ratified through HR      exists,  and     work
                                                                                                             Strategy Group. Available       continues            in
                                                                                                             on Intranet. Briefing to        partnership with staff
                                                                                                             Managers/PCT staff              side – ongoing. This
                                                                                                                                             policy has been
                                                                                                                                             reviewed,
                                                                                                                                             completed          and
                                                                                                                                             implemented.

                          Review the Equality and Diversity                 Joanne              September    Appointment of Equality         Equality & Diversity
                          Schemes and ensure organisational                 Marvell             2008         and Diversity Manager           Manager appointed
                          compliance.                                                                        Equality Impact Assessment      and programme of
                                                                                                             (EIA) of HR Policies and        work/ activities in
                                                                                                             Services                        place and currently
                                                                                                             Equality Impact Assessment      being actioned.
                                                                                                             Training – key attendance       E&D          Manager
                                                                                                             from HR personnel               delivers      Equality
                                                                                                             Publicised EIA‟s on Internet.   Impact Assessment
                                                                                                             Disability Equality Scheme –    (EIA) training once
                                                                                                             accepted by Equality and        a month, which is
                                                                                                             Human Rights Commission         accessible to all
                                                                                                             Self      Assessment       of   managers or staff
                                                                                                             compliance with Gender          who              write
                                                                                                             Equality Scheme – SHA           policies/strategies or
                                                                                                             submission (end of April        managing service.
                                                                                                             2008)




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                               48
  Development/                        Key Aim/Objective                          Lead               Target    Performance Measure   Reported Progress
     Topic                                                                     Person(s)             Date
Developing        the Review the Equality and Diversity                     Joanne              September    Cont/d.                Completed EIA‟s are
Workforce / Lifelong Schemes and ensure organisational                      Marvell             2008                                published on the
Learning (Cont’d.)    compliance (cont/d).                                                                                          website and the
                                                                                                                                    next update of EIAs
                                                                                                                                    to be put onto the
                                                                                                                                    website by end of
                                                                                                                                    Feb 2009.
                                                                                                                                    Final      Disability
                                                                                                                                    Equality   Scheme
                                                                                                                                    (DES) submitted to
                                                                                                                                    the Equality and
                                                                                                                                    Human      Rights
                                                                                                                                    Commission
                                                                                                                                    (EHRA).
                                                                                                                                    Continual
                                                                                                                                    communication with
                                                                                                                                    the      EHRA     in
                                                                                                                                    response to the DES.
                                                                                                                                    Last
                                                                                                                                    correspondence
                                                                                                                                    was positive from
                                                                                                                                    the EHRA to the PCT
                                                                                                                                    in relation to the
                                                                                                                                    DES.
                                                                                                                                    Work continuing on
                                                                                                                                    the Gender Equality
                                                                                                                                    Scheme (GES) and
                                                                                                                                    self-assessment   of
                                                                                                                                    the GES was sent on
                                                                                                                                    time to the SHA.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                     49
Third Domain - Governance


Domain Outcome:               Managerial and clinical leadership and accountability, as well as the organisation’s culture, systems and
                              working practices ensure that probity, quality assurance, quality improvement and patient safety are central
                              components of all the activities of the healthcare organisation


   Development/                   Key Aim/Objective                      Lead            Target Date       Performance Measure               Reported
      Topic                                                            Person(s)                                                             Progress
PROVIDER DIVISION

Strengthening      the     Review the Provider Division‟s Hilary Garratt               31 October      Further development of Divisional Assurance
Provider      Division     organisational   structure    to                            2008            structure     and     assurance framework to be
Governance                 enable each level to seek and                                               framework.                        completed
arrangements               receive assurance from the next.                                                                              following the
                                                                                                                                         approval of the
                                                                                                                                         2009-2012
                                                                                                                                         business plan .

                           Review the membership and Hilary Garratt                    31 October      Clear Terms of reference, work Terms of
                           remit of the Provider Healthcare                            2008            programme      and     reporting reference
                           Governance Group.                                                           framework established.           including
                                                                                                                                        membership
                                                                                                                                        agreed.

Information                Review Provider representation Hilary Garratt/              30 June 208     Provider membership clear and     Membership
Technology                 on the PCT‟s IM&T group and Zoe Mellon                                      evidence of feeding back to the   agreed and
                           comment on the PCT‟s IM&T Plan                                              Provider   Directorate‟s Senior   issues highlighted
                           for 2008/09 and beyond, and                                                 Management         Team    and    through SMT
                           identify a reporting structure for                                          producing action plans when
                           divisional    feedback        and                                           responses are required.
                           responses



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        50
   Development/                   Key Aim/Objective                      Lead            Target Date       Performance Measure              Reported
      Topic                                                            Person(s)                                                            Progress
                           Project Rome                             Hilary Garratt     31 March 2009   100% of employees have access    Activity levels
                                                                                                       to a computer.     Increase in   increasing as
                                                                                                       activity levels recorded on      data cleansing
                                                                                                       Lorenzo.                         process
                                                                                                                                        occurring. Staff
                                                                                                                                        given Lorenzo
                                                                                                                                        reports to
                                                                                                                                        improve
                                                                                                                                        outcome activity
                                                                                                                                        on Lorenzo.
Information                Further roll out the use of mobile Hilary Garratt           31 March 2009   100% use of Lorenzo              Within service
Technology (Cont’d.)       technology for Lorenzo reporting. /John Hanson                                                               review process
                                                                                                                                        staff identified
                                                                                                                                        when shortfall in
                                                                                                                                        reporting. Action
                                                                                                                                        Plan put in place,
                                                                                                                                        awaiting
                                                                                                                                        confirmation from
                                                                                                                                        OTHIS if they are
                                                                                                                                        able to facilitate
                                                                                                                                        this process.

                           Populate the Provider element of Hilary Garratt/            31 March 2009   Intranet page for each service Intranet pages
                           the newly designed intranet.     Zoe Mellon                                 area                           being populated
                                                                                                                                      with relevant
                                                                                                                                      data. Eg. minutes
                                                                                                                                      and agendas.
                                                                                                                                      Further work
                                                                                                                                      needs to be done
                                                                                                                                      to complete the
                                                                                                                                      process




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                      51
   Development/                   Key Aim/Objective                      Lead            Target Date        Performance Measure                 Reported
      Topic                                                            Person(s)                                                                Progress
                           Refine      Provider    Division‟s Hilary Garratt/          31 October      KPI reporting further developed.      KPI‟s identified
                           management           information Zoe Mellon                 2008            Performance Accelerator in use.       and reported to
                           systems and establish a clear                                               Enhanced       Lorenzo    reporting   SMT Provider
                           reporting framework.                                                        system implemented.                   Board and
                                                                                                       Job roles identified, evaluated       Commissioning
                                                                                                       and recruited.                        Performance
                                                                                                                                             meeting.
                                                                                                                                             Performance
                                                                                                                                             accelerator used
                                                                                                                                             for risk register
                                                                                                                                             Provider audit
                                                                                                                                             calendar and
                                                                                                                                             service review
                                                                                                                                             action points.
                                                                                                                                             Lorenzo
                                                                                                                                             implemented
                                                                                                                                             and reporting
                                                                                                                                             now more
                                                                                                                                             sophisticated .
                                                                                                                                             Recruitment to
                                                                                                                                             performance
                                                                                                                                             team now
                                                                                                                                             complete.

Learning &                 Prepare a divisional plan that Hilary Garratt/              31 October      Job roles identified, evaluated Work ongoing
Development                supports implementation of the Zoe Mellon                   2008            and posts recruited to.         with HR to
                           PCT‟s workforce strategy with                                                                               complete a
                           clear objectives for 2008/09 and                                                                            Workforce
                           2090/10.                                                                                                    Development
                                                                                                                                       Plan




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           52
   Development/                   Key Aim/Objective                      Lead            Target Date       Performance Measure            Reported
      Topic                                                            Person(s)                                                          Progress
                           Collate information centrally in Hilary Garratt/            31 October      Development and mentoring Pathways
                           respect of the professional Zoe Mellon                      2008            pathways to be available for continue to be
                           development         pathways  to                                            communication and planning.  developed.
                           enable         these     to  be                                                                          Various
                           communicated in recruitment                                                                              development
                           and       service    development                                                                         sessions planned
                           activities.                                                                                              for community
                                                                                                                                    nursing workforce
                                                                                                                                    to facilitate
                                                                                                                                    movement along
                                                                                                                                    the pathways
                                                                                                                                    programme.

                           Develop          an          internal Hilary Garratt/       31 October      Provision of evidence of the Training package
                           communication            programme Zoe Mellon               2008            implementation     of    the delayed due to
                           highlighting priorities.                                                    communication programme.     non-delivery of
                                                                                                                                    Voice Over
                                                                                                                                    Internet phones

                           Establish   a      learning and Hilary Garratt/             31 October      Provision of evidence that the NVQ in both
                           development programme for Zoe Mellon                        2008            programme is available.        Business Studies
                           community clinic administration                                                                            and Customer
                           and clerical staff.                                                                                        Care available.
                                                                                                                                      Staff attendance
                                                                                                                                      dependent on
                                                                                                                                      outcome of PDP.
                                                                                                                                      4 individuals
                                                                                                                                      attended Apr‟08
                                                                                                                                      – Mar‟09.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                    53
   Development/                   Key Aim/Objective                      Lead            Target Date        Performance Measure               Reported
      Topic                                                            Person(s)                                                              Progress
Financial                  Finalise  the  recruitment of Hilary Garratt                31 October      Job holders in post                 Associate
Governance                 jobholders for a devolved                                   2008                                                Director, Finance,
                           finance function in Provider                                                                                    now in post
                           Division.

                           Review the divisional function Hilary Garratt               31 October      Work programme in place.            Finance work
                           and      highlight development                              2008                                                programme in
                           priorities and establish a work                                                                                 place
                           programme for 2008/09.

Service Development        Develop   a    team  in    the Hilary Garratt               31 October      Job roles identified, evaluated Development
                           Development and Performance                                 2008            and recruited.                  and Performance
                           Unit   to    support   service                                                                              unit roles and
                           development.                                                                                                responsibilities
                                                                                                                                       being developed
                                                                                                                                       under the
                                                                                                                                       leadership of
                                                                                                                                       Associate
                                                                                                                                       Director, Finance.

                           Develop tools and controls Hilary Garratt                   31 October      Systems and processes identified.   Service review
                           which support the development,                              2008                                                process
                           design,      redesign       and                                                                                 implemented
                           implementation of roles and
                           services and prevent duplication
                           of effort.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           54
   Development/                   Key Aim/Objective                      Lead            Target Date        Performance Measure                  Reported
      Topic                                                            Person(s)                                                                 Progress
CATS                       Develop a mechanism to ensure Anne Rothery/                 June 2008       Clear algorithm of responsibilities.   Algorithm written
                           safe, clinical governance of Raj Gulati                                     Clear outline in contract.             and agreed
                           pathways and projects.                                                                                             across Greater
                                                                                                                                              Manchester.
                                                                                                                                              Clinical
                                                                                                                                              Governance
                                                                                                                                              framework
                                                                                                                                              agreed across
                                                                                                                                              Greater
                                                                                                                                              Manchester, with
                                                                                                                                              clear reporting
                                                                                                                                              and
                                                                                                                                              accountability
                                                                                                                                              arrangements
                                                                                                                                              now in place.

Caldicott Issues           Ensure safe transfer of patient Richard Fitton              By December     Communication      of    function Work ongoing
                           data.                                                       2008            throughout the organisation.      around
                                                                                                                                         education and
                                                                                                                                         training on
                                                                                                                                         records creation
                                                                                                                                         and access.
                                                                                                                                         Caldicott
                                                                                                                                         Guardian to
                                                                                                                                         undertake 2
                                                                                                                                         sessions per week
                                                                                                                                         from April 2009.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            55
Fourth Domain – Patient Focus


Domain Outcome:               Healthcare is provided in partnership with patients, their carers and relatives, respecting their diverse needs,
                              preferences and choices, and in partnership with other organisations (especially social care organisations)
                              who se services impact on patient well-being


     Development/                  Key Aim/Objective            Lead Person(s)          Target Date   Performance Measure           Reported Progress
        Topic
COMMISSIONING
DIVISION

Improved Palliative Care

 End of Life Care              Continue the roll out of Pauline Sumner              Ongoing          Audit of patient outcome   66 care home patients
  Programme          (NHS       GSF/LCP education/                                                                               have been through the
  2005)                         training programmes to                                                                           GSF         programme,
  Guide to End of Life          Care Homes regarding                                                                             commenced on LCP and
  care in Care Hones            end of life care tools                                                                           maintained within the
  (NHS 2006)                    aimed      at   improving                                                                        nursing home for end of
                                palliative care provision,                                                                       life care.
   GSF/LCP    in    Care       anticipatory care and the
    Homes incorporating         reduction      of      crisis
    advance care plans          inappropriate     hospital
    and anticipatory care       admission at end of life.
    planning.

 Preferred Priorities of Introduction of Preferred Pauline Sumner                   Launch of PPC Implementation of PPC Multi-agency Working
  Care (PPC) document. Priorities      of     Care                                   tool   January tool                 Group established to
                          document                                                   2009                                develop our own
                                                                                                                         document, which will
                                                                                                                         incorporate PPC. Work in
                                                                                                                         progress.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                       56
     Development/                  Key Aim/Objective            Lead Person(s)          Target Date      Performance Measure           Reported Progress
        Topic
Working    with       partner Ensure that service users John Hazelhurst              Ongoing            Models for engagement      A model for service user
organisations                 and        carers     are                              development        reported through Joint     and carer involvement is
                              meaningfully involved in,                              and                Commissioning              in place and is modular in
                              and integral to, the                                   implementation.    Governance framework.      its approach. In this
                              procurement       process,                                                                           respect, it allows
                              including service design                                                                             involvement at any stage
                              and tender evaluation                                                                                of the procurement cycle
                              through to performance                                                                               and is not reliant upon
                              management             of                                                                            starting at the needs
                              contracts.                                                                                           assessment stage.
Consent/Consent Training        Ensure all appropriate Kay Worsley-                  April 2009         Attendance monitoring      Consent training now part
                                staff   receive     consent Cox                                                                    of the annual training
                                training within 2 years                                                                            programme.

                             Ensure consent is gained Hilary May                     In place       and NHS/DH guidance            In place and ongoing
                             from the caller at the                                  ongoing
                             outset where third party
                             services have to be used
                             to assist the patient, for
                             example Language Line.
Patient    leaflets      and Ensure     that     patient Naomi Duggan                Ongoing            The number of leaflets Publications            Policy
literature                   leaflets   and literature                                                  produced via the official published. Some leaflets
                             follow    the    guidelines                                                process.                  being produced via the
                             published in the PCT‟s                                                                               identified process. Difficult
                             Publications Policy                                                                                  to ascertain how many
                                                                                                                                  are       produced         in
                                                                                                                                  department that are not
                                                                                                                                  brought to the attention of
                                                                                                                                  communications.
                                                                                                                                  Member of staff been
                                                                                                                                  appointed       to       the
                                                                                                                                  communications team to
                                                                                                                                  lead on this.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           57
     Development/                  Key Aim/Objective            Lead Person(s)          Target Date   Performance Measure         Reported Progress
        Topic
Dignity in Care                 Ensure that people using
                                healthcare services are
                                treated with dignity and
                                respect:

                                 Develop                user Hitesh                      Ongoing     Robust        feedback    Joint PALS with TGH –
                                  feedback                    Chandarana                              mechanisms developed      being developed under
                                  mechanisms                                                          with all secondary care   Competency 3 action
                                                                                                      providers                 plan.

                                 Develop the Patient Hitesh                              Nov 2007    The Group setting the Group meeting on bi-
                                  Reference Group to Chandarana                                       agenda to monitor DiC monthly basis – new user
                                  monitor DiC issues for                                              issues for the PCT    mechanisms      to      be
                                  the PCT                                                                                   introduced during 2009.

                                 Undertake     a    user Hitesh                        August 2008   Survey       undertaken, Bids for tender currently
                                  satisfaction survey to Chandarana                                   results  analysed   and being considered.
                                  gauge           patient                                             action plan developed.
                                  experience           in
                                  secondary services

Patient Experience              Develop    a     Patient Hitesh                         August 2008   An overarching strategy Currently being jointly
                                Experience Strategy for Chandarana                                    in place to cover all agreed by Public Affairs
                                the PCT                                                               services  commissioned and PE functions.
                                                                                                      and provided by the PCT




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                       58
     Development/                 Key Aim/Objective             Lead Person(s)         Target Date    Performance Measure         Reported Progress
        Topic
                                Ensure qualitative patient Hitesh                       August 2008   A robust implementation Papers agreed at EMT and
                                responses           inform Chandarana                                 plan for PE strategy    Board.
                                commissioning decisions

                                Continued development Hitesh                              Ongoing     All PALS data   informs PALS produce a monthly
                                of the PALS           Chandarana                                      commissioning           report which is considered
                                                                                                      discussions             by the Commissioners.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                     59
     Development/                  Key Aim/Objective            Lead Person(s)          Target Date       Performance Measure               Reported Progress
        Topic
Equality and Diversity          Deliver     generic    E&D Melanie Birtles           June 2008            All new      and varied Completed. As from April
                                contractual       and   SLA                                               contracts    include the 2008, all standards SLAs
                                clauses     that    capture                                               clauses                  and contracts currently in
                                service providers E&D                                                                              use were reviewed and
                                responsibilities.                                                                                  E&D clauses included, to
                                                                                                                                   capture PCT
                                                                                                                                   responsibilities.

                                                                                                          EDMA signs off the For SLAs developed by
                                                                                                          generic clauses as fit for ourselves, a draft clause
                                                                                                          purpose.                   was submitted and signed
                                                                                                                                     off by EDMA as fit for
                                                                                                                                     purpose.

                                Deliver a performance Melanie Birtles                June 2008            Sign off as Fit for Purpose    Performance
                                management framework                                                      by Equality Diversity and      Management framework
                                that can be utilised for all                                              Monitoring          Advisory   In development.
                                contractual or service                                                    Group (EDMA).                  This is an area for review
                                level agreements.                                                                                        during 2009/10.

Management of Patient Develop          intelligence Ben Dearden                      31/07/08           Agreed      protocols     in     Now being delivered via
Experience/Satisfaction systems     to      support                                                     place      for    capture,       WCC Competency 3
Intelligence            management of patient                                                           management             and       action plan.
                        experience/satisfaction                                                         reporting     of    patient
                        indicators.                                                                     experience/satisfaction
                                                                                                        indicators.
Patient Experience/             Assessment, Booking and Hilary May                   In place       and All calls managed using          In place and ongoing.
Patient User Groups             Choice Service continues                             ongoing            this service are subject to
                                to offer interpretation                                                 audit
                                services  as    standard
                                through Language Line
                                service


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                 60
     Development/                  Key Aim/Objective            Lead Person(s)          Target Date      Performance Measure        Reported Progress
        Topic
Patient Experience/             Ensure patients who are Hilary May                   In place       and All calls managed using In place and ongoing.
Patient User Groups             hearing impaired can                                 ongoing            this service are subject to
(Cont’d.)                       access the service using                                                audit.
                                Type Talk and all staff are
                                trained in both disciplines.


Use and disclosure of Ensure all staff joining the Hilary May                        In place       and Based on NHS Guidelines In place and ongoing.
confidential information. Assessment, Booking and                                    ongoing            for Confidentiality
                          Choice Service continue
                          to have training on
                          Confidentiality


Complaints System               Ensure all Assessment, Hilary May                    In place       and NHS complaints policy In place and ongoing.
                                Booking and Choice staff                             ongoing            and T&G PCT complaints
                                dealing     with   patient                                              procedure.
                                enquiries to continue to
                                receive an overview of
                                the complaints procedure
                                in     their     induction
                                programme to enable
                                them to guide callers
                                appropriately.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                       61
Fourth Domain – Patient Focus


Domain Outcome:               Healthcare is provided in partnership with patients, their carers and relatives, respecting their diverse needs,
                              preferences and choices, and in partnership with other organisations (especially social care organisations)
                              who se services impact on patient well-being


   Development/                Key Aim/Objective               Lead Person(s)         Target Date       Performance                 Reported Progress
      Topic                                                                                               Measure

PROVIDER DIVISION

Choice                     Transfer of patient booking Hilary Garratt/                March 2009    Increased number of All services are identifying
                           incrementally to the ABC AD Group                                        bookings through the areas for potential transfer to
                           Service.                                                                 ABC Centre.          the ABC centre,




Patient Information        Produce                 service Hilary Garratt/            March 2009    Production of a service   Marketing material for all new
/Communication             prospectus                   for AD Group                                development        and    services is available.
                           new/redesigned         services                                          implementation            Checklist to be used when
                           for the Intranet.                                                        checklist.                tendering for all new services in
                                                                                                                              development.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           62
   Development/                 Key Aim/Objective              Lead Person(s)         Target Date       Performance               Reported Progress
      Topic                                                                                               Measure
User Involvement           Integrate         patient
                           engagement into services:-

                               Create              an Hilary Garratt/                March 2009    Patient satisfaction/   Project work ongoing to
                                understanding        of John Hanson                                 feedback                identify areas of patient
                                patient and public                                                                          experience and where this
                                involvement for all our                                                                     could be of benefit across the
                                staff.                                                                                      services as a whole . Report
                                                                                                                            expected Mid March 2009 to
                               Establish training for all                                                                  be presented to Provider Board
                                our      staff    around
                                different methods of
                                engagement.

                               Identify ways that our                                                                      Podiatry telephone audit
                                 staff can feedback                                                                         /survey completed and
                                 examples of patient                                                                        submitted to Provider
                                 and            public                                                                      Healthcare Governance
                                 involvement and use                                                                        Committee on 3/3/09, and
                                 them as examples of                                                                        Clinical Audit Task Group on
                                 best practice across                                                                       24/3/09. Also to Provider
                                 the Division.                                                                              Healthcare Audit Group.

                               Include PPI as a core
                                 theme    within     our
                                 service         review
                                 mechanisms.                                                                                Service review document
                                                                                                                            supports staff to identify service
                                                                                                                            specific patient engagement




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                          63
Fifth Domain – Accessible and Responsive Care


Domain Outcome: Patients receive services as promptly as possible, have choice in access to services and treatments, and do not
                experience unnecessary delay at any stage of service delivery or the care pathway

    Development/               Key Aim/Objective             Lead Person(s)            Target Date     Performance Measure          Reported Progress
       Topic
COMMISSIONING                Ensure           health Claire Watson/                  September 2008   Protocol    for     service Implemented prior to
DIVISION                     development        and Alison Leigh                                      redesign in place and March 2009.
                             care pathway redesign                                                    records    of     patient/
Patient Involvement          protocols will include                                                   community     involvement
                             patient     experience                                                   taken.
                             information        and
                             patient involvement in
                             design of pathways.

                             Ensure that patients Claire Watson                      September 2008   As above                   As above
                             and communities are /Alison Leigh
                             actively involved in the
                             development of the
                             PCT‟s strategic plan.

                             Ensure             Needs Sabrina Fuller                 Ongoing          Needs           assessment Not yet formalised,
                             assessments       include                                                protocols in place         however, work underway
                             patient     input     and                                                                           to include Patient
                             qualitative         data,                                                                           Involvement.
                             including patient and
                             user views.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        64
     Development/              Key Aim/Objective             Lead Person(s)            Target Date    Performance Measure            Reported Progress
        Topic
                             Service specifications        Claire Watson             Ongoing         Service Specification        The Health Development
                             will require providers to                                                                            and Service Redesign
                             demonstrate         user                                                                             Team will implement the
                             involvement in service                                                                               use of the national
                             design, development                                                                                  standard service
                             and review                                                                                           specification (as part of
                                                                                                                                  the Community Contract)
                                                                                                                                  and will ensure KPIs
                                                                                                                                  include provider
                                                                                                                                  collection of user and
                                                                                                                                  patient satisfaction data.
Patient Access                Improve access to Mary Callan                          December 2008   Contracts awarded for GP Milestones achieved:-
  Equitable Access          primary         medical                                                 lead, HC and 3 new
                             services              by                                                practices.                    Service specification
                             commissioning                                                                                         Consultation
                             additional     practices                                December 2009   Services in operation for all Formal procurement
                             and increase number                                                     4 schemes.                    Providers identified
                             of clinicians.                                                                                        Contracts awarded

    Dental      Access      Provide a service to Janet Bunyan/                      From May 2008   Monitoring of quality and   Two Dental Access
     Centre (and dental      deliver routine dental Anita Maniak                                     performance will use data   Centres commissioned:
     access    slots  in     care to patients who                                                    from a variety of sources   Hyde in June 2008 and
     general      dental     are unable to obtain                                                    which is discussed with     Glossopdale in January
     practice)               care in the General                                                     provider.                   2009. Five general dental
                             Dental Service                                                                                      practices also
                                                                                                     Review meetings held commissioned to provide
                                                                                                     monthly for 3 months, then routine access slots, with
                                                                                                     quarterly for the following effect from October 2008.
                                                                                                     12 months.                  Currently, there are no
                                                                                                                                 patients on the PCT
                                                                                                                                 waiting list for routine
                                                                                                                                 dental care.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                          65
    Development/               Key Aim/Objective             Lead Person(s)            Target Date      Performance Measure            Reported Progress
       Topic
Improved         Palliative Increased availability         Margaret Hayes /          From 1st April for Number of contacts to the   Pilot undertaken.
Care                        of a Palliative Care           Specialist Palliative     6        months. service, source of referral   Evaluation report
                            Clinical    Nurse    9-5       Care team.                Review October and referral details.           available. Weekend
                            weekends to provide                                      2008                                           availability not in place at
                            face-to-face                                                                                            present.
                            assessment.
Policy for Verification of Introduction       of   a       Margaret Hayes            To review         Increased provision of       Staff training undertaken
Expected Death (VOD) Verification                 of                                 November 2008     support by community         and policy introduced.
for Nurses                  Expected Death (VOD)                                                       nurses,  in  cases  of       Policy NOW available on
                            Policy for nurses.                                                         expected death.              the internet
Choose and Book              Improve utilisation of Louise Roberts                   June 2008         Implement        project Direct Incentive Scheme
                             Choose and Book and                                                       management tools.        in place for Choose and
                             Freedom of Choice                                                                                  Book.
Contract and           SLA Delivery of contracts Mark Shrimpton                      June 2008         All    new      contracts    All new contracts have
Management                 and SLA‟s with Fit for                                                      demonstrate KPI‟s that       FFP KPIs but not
                           Purpose KPI‟s                                                               allow    for testing   of    associated with
                                                                                                       responsive care without      responsive care. New
                                                                                                       unnecessary delay.           NHS Ambulance contract
                                                                                                                                    in place currently being
                                                                                                                                    allocated across the
                                                                                                                                    team.
                        Demonstrably          high Mark Shrimpton                    June 2008 and     All  new   and   varied
                        quality    performance                                       ongoing           contracts being actively
                        monitoring            and                                                      managed.
                        application             of
                        contractual controls.
Management of Patient Develop        intelligence Ben Dearden                        31/07/08          Agreed protocols in place Now being delivered via
Experience/Satisfaction systems     to    support                                                      for capture, management WCC Competency 3
Intelligence            management              of                                                     and reporting of patient action plan.
                        patient                                                                        experience/satisfaction
                        experience/satisfaction                                                        indicators,    specifically
                        indicators.                                                                    relating to Access and
                                                                                                       Choice.


NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            66
    Development/               Key Aim/Objective             Lead Person(s)            Target Date         Performance Measure            Reported Progress
       Topic
Access and Choice            All patients accessing Hilary May                       In place       and GP patient survey which Annual DH Survey
                             the         Assessment,                                 ongoing            includes  access     and undertaken. Final
                             Booking and Choice                                                         choice undertaken by DH. analysis showed 597
                             Service to continue                                                                                 respondents: 58% recall
                             being offered a range                                                                               being offered a choice of
                             of choices with regard                                                                              provider, 38% were not,
                             to venue, date and                                                                                  with 4% uncertain. Of the
                             time of appointment.                                                                                58% that were offered a
                                                                                                                                 choice, 77% were able to
                                                                                                                                 book an appointment at
                                                                                                                                 the provider of their
                                                                                                                                 choice.

Seeking     views     of Ensure           patients Hilary May                        In place       and As above and also by DH        DH produce weekly
patients/carers/local    attending    their    GP                                    ongoing            reporting   on      activity   report on activity taking
community                have the opportunity                                                           through Choose and Book        place between C&B. Our
                         to discuss their choices                                                       System and TAL utilisation.    current position shows
                         at    the     time     of                                                                                     77% of patients having
                         consultation        and,                                                                                      first outpatient
                         where           possible,                                                                                     appointment booked
                         appointments       made                                                                                       through C&B (National
                         by using the Choose                                                                                           target for C&B utilisation is
                         and Book system.                                                                                              75%.)




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                67
Fifth Domain – Accessible and Responsive Care


 Domain Outcome: Patients receive services as promptly as possible, have choice in access to services and treatments, and do not
                 experience unnecessary delay at any stage of service delivery or the care pathway


   Development/                 Key Aim/Objective                Lead Person(s)             Target Date      Performance              Reported Progress
      Topic                                                                                                    Measure
PROVIDER DIVISION

Access                     Provide   an  Out-of-Hours John Hanson                        October 2008     Increased      choice Evening service was
                           NOUS service i.e. evening                                                      to patients           established prior to move to
                           and Saturday morning.                                                                                Ashton PCC. Provision of
                                                                                                                                further Out of Hours services
                                                                                                                                is under review, and the
                                                                                                                                service can flex to ensure
                                                                                                                                that all patients are seen
                                                                                                                                within designated waiting
                                                                                                                                times.

Service Specification      Increase the number of John Schooling                         September 2008   Number    of     beds Commissioned for 17 beds,
                           stroke rehabilitation beds                                                     open.                 all now open.
                           from 10 to 21.

                           Actively manage service Hilary Garratt                        March 2009       Use of waiting list Waiting list function
                           waiting times. Replace the                                                     function in Lorenzo monitored. Routine and
                           current    paper     based                                                                         regular reports available to
                           reporting system with an                                                                           managers. Action plans
                           automated         technical                                                                        developed to reduce any
                           solution.                                                                                          waiting times, with priority
                                                                                                                              being given to any over 18
                                                                                                                              weeks .



NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                          68
Sixth Domain – Care Environment and Amenities


Domain Outcome: Care is provided in environments that provide patient and staff well-being and respect for patients’ needs and
                preferences, in that they are designed for the effective and safe delivery of treatment, care or a specific function as
                much privacy as possible, are well maintained and are cleaned to optimise health outcomes for patients


   Development/             Key Aim/Objective             Lead Person(s)             Target Date     Performance Measure             Reported Progress
      Topic
COMMISSIONING                                                                                                                   Strategic Project on target.
DIVISION                                                                                                                        Ashton PCC fully
                                                                                                                                operational. Glossop PCC
LIFT                       Monitor progress of Louise Rigg                        June 2008         Implement           Project on target to reach
                           strategic project.                                                       Management tools and financial close by end April
                                                                                                    regular progress reports.   2009. Regular reports to
                                                                                                                                EMT, PEC & Board.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         69
Sixth Domain – Care Environment and Amenities


Domain Outcome: Care is provided in environments that provide patient and staff well-being and respect for patients’ needs and
               preferences, in that they are designed for the effective and safe delivery of treatment, care or a specific function as
               much privacy as possible, are well maintained and are cleaned to optimise health outcomes for patients


    Development/                      Key Aim/Objective                      Lead             Target Date   Performance Measure           Reported Progress
       Topic                                                               Person(s)
PROVIDER DIVISION
Ashton Primary Care Maintain business continuity during Hilary Garratt/                     January 2009    Opening     of   the   new All Provider Division
Centre              the transfer of services from AD Group                                                  building.                  services transferred to
                    existing buildings to the Primary                                                                                  Ashton PCC and fully
                    Care Centre in Ashton.                                                                                             operational.

Estates Strategy              Review the Provider Division‟s Hilary Garratt/                March 2009      Action Plan available.       Now agreed that a
                              Estates Strategy in line with service Chris Ryan                                                           report of building use
                              provision and development, for                                                                             profiles to be
                              consideration     by      the    PCT                                                                       prepared before
                              Committee Structure.                                                                                       commencing on an
                                                                                                                                         Estate Strategy.
                                                                                                                                         Information to be
                                                                                                                                         ready by end of April.

Dignity in Care               Ensure that all patients have a Nikki Leach                   Sept‟08         Dignity   in           Care Dashboard provides
                              care plan, which addresses their                                              dashboard                   evidence that
                              individual needs, meets the                                                                               standards for
                              standards for contracts around                                                                            contracts are met.
                              dignity in care and reflects the                                                                          All parties have care
                              Provider Division‟s strategy to                                                                           plans which are
                              ensure dignity in care underpins                                                                          individualised.
                              service delivery.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                           70
   Development/                     Key Aim/Objective                        Lead             Target Date    Performance Measure          Reported Progress
      Topic                                                                Person(s)
PEAT Review for Shire      Ensure the PCT continues to achieve          Chris Ryan          End of March Undertake Annual review Visit arranged for 30th
Hill Hospital and          „excellent‟ results.                                             2009         as per DH requirements & 31st March and
Stroke Rehabilitation                                                                                    and submit findings.    report to be with DH
Unit                                                                                                                             by 3/4/09 to meet
                                                                                                                                 timeframe.

PEAT Review for Shire      Set up quarterly reviews of both sites Chris Ryan                Ongoing          Each quarterly review to Meetings set up for
Hill   Hospital  and       and     carry     out   follow     up                            throughout the   be documented            the    year      and
Stroke Rehabilitation      maintenance needs to ensure                                      year                                      Maintenance
Unit (Cont’d.)             standards are maintained.                                                                                  Manager          now
                                                                                                                                      undertaking reviews.

Waste Management           Work with local authorities to Chris Ryan                        Ongoing          More    efficient   waste    Regular meetings to
                           develop more effective waste reuse,                              throughout the   streams identified (would    be arranged with
                           recycling and disposal methods.                                  year             be confirmed as part of      local        authority
                                                                                                             Annual Audit process)        counterparts

Energy Management          Staff awareness training to ensure Chris Ryan                    April/May 2009   Key staff identified and     Agency staff now in
                           that energy consumption is reduced                                                trained.   Lower energy      place to manage
                           as much as possible.                                                              consumption        figures   energy         system.
                                                                                                             being reported.              Training    to      be
                                                                                                                                          arranged            for
                                                                                                                                          April/May 2009.

                           Design low energy lighting system Chris Ryan                     End     March    Lighting      schemes        Surveys      currently
                           and suitable premises, source                                    2009 for all     completed at selected        underway,     scheme
                           funding and implement changes.                                   selected         premises (Subject   to       costs identified by
                                                                                            premises         funding)                     early March. Limited
                                                                                                                                          funds identified in
                                                                                                                                          Capital Programme.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                             71
   Development/                     Key Aim/Objective                        Lead             Target Date     Performance Measure            Reported Progress
      Topic                                                                Person(s)
Sustainable Transport      Implement a phased, sustainable Chris Ryan                       Overall    this   Staff travel habits survey    All surveys completed
                           transport and access strategy                                    initiative will   undertaken.                   and reports now with
                                                                                            probably take     Patient      getting     to   Public Health who are
                                                                                            18 months or      healthcare appts‟ survey      leading      on   this
                                                                                            so          to    undertaken.                   initiative.
                                                                                            complete          Determination       of    a
                                                                                                              costed action plan and
                                                                                                              obtain      approval     to
                                                                                                              funding.
Sustainable                Implement a phased sustainable Chris Ryan                        Overall    this   All procurement streams       Report now handed
Procurement                procurement strategy.                                            initiative will   identified        including   over to Public Health
                                                                                            probably take     „quick wins‟.      Relevant   who are now leading
                                                                                            18 months or      procurement streams fully     on this initiative.
                                                                                            so          to    reviewed               and    Awaiting            next
                                                                                            complete          sustainability options and    Sustainability meeting
                                                                                                              savings determined.           for feedback.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                                72
Seventh Domain – Public Health


Domain Outcome: Programmes and Services are designed and delivered in collaboration with all relevant organisations and
              communities to promote and improve the health of the population served and reduce health inequalities between
              different population groups and areas


   Development/                  Key Aim/Objective                Lead Person(s)          Target Date    Performance Measure          Reported Progress
      Topic
COMMISSIONING        Development        of    service Melanie Sirotkin                  May 2008        Service specifications in Service specifications
DIVISION             specifications signed off for                                                      place for key health well underway. LEAN
                     health            improvement                                                      improvement services.     review completed and
Health Promotion and programmes that will reduce                                                                                  revision of specifications
Prevention           inequalities by focusing on key                                                                              imminent.
Programmes           health issues and areas of
                     highest needs.

                           Agree key public health Melanie Sirotkin                     August 2008     Targets   agreed    and Targets agreed and
                           targets    through    Tameside                                               quarterly     monitoring monitored.
                           Strategic    Partnership    and                                              implemented.
                           Derbyshire             Strategic
                           Partnership    and    delivered
                           through LAA and operational
                           plan.

Reducing         Health Revision of the Spearhead Melanie Sirotkin/                     September    Strategy in place              Strategy reviewed and
Inequalities            structure and the Health Debbie Bishop/                         2008    then                                revised by TMBC Health
                        Inequalities     Strategy   – James Matthews                    ongoing                                     Participation Board in
                        including the development of                                                                                May 2008. In
                        Tameside Health and Well                                                                                    consequence,
                        Being Strategy and equivalent                                                                               presented to PCT Board.
                        for Glossopdale.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         73
   Development/                  Key Aim/Objective                Lead Person(s)          Target Date    Performance Measure          Reported Progress
      Topic
Reducing        Health Development of a Health Sabrina Fuller                           July 2008       Equity audits informing     Ongoing programme.
Inequalities (Cont’d.) Equity Audit Programme.                                                          commissioning    through    Chlamydia Screening
                                                                                                        PEC    and    Board   as    Equity Audit completed
                                                                                                        appropriate.                March 2009.

                           PCT continues to chair the Melanie Sirotkin/                 Ongoing         Teenage       pregnancy Strategy revised and
                           Teenage Pregnancy Executive Tim Riley                                        Strategy and action plan. Executive Board now
                           and     ensures  a    work                                                                             managing performance.
                           programme is in place to
                           address teenage conceptions
                           in Tameside.

                           PCT works with partners to Melanie Sirotkin                  Ongoing         Strategies  in     place. Ongoing management.
                           ensure delivery of the Obesity                                               Quarterly monitoring and
                           Strategy, Alcohol Strategy,                                                  performance
                           Substance Misuse Strategy and                                                management.
                           Sexual Health Strategy based
                           on needs assessment and
                           delivery of key programmes of
                           targeted activity.

Director of Public Production of an annual report Melanie Sirotkin                      July 08         Annual Report produced Annual Report produced
Health Annual Report which                 includes                                                     and informing and driving and used to inform CSP
                     recommendations used to                                                            Operational Plan and and Operational plan.
                     drive commissioning decisions.                                                     Commissioning Cycle.

                           Ensure report is disseminated Melanie Sirotkin               Aug-Sep 08      Report presented to PCT     Presented to Board on
                           to local partners and reported                               Ongoing         PEC and Board and           12/11/08, Tameside
                           through     both     PCT  and                                                Tameside           Health   Health Partnership on
                           Partnership structures.                                                      Partnership          and    5/12/08. And to PEC on
                                                                                                        Derbyshire Health & Well    17/12/08.
                                                                                                        Being Partnership.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         74
   Development/                  Key Aim/Objective                Lead Person(s)          Target Date    Performance Measure          Reported Progress
      Topic
Emergency                  Ensure the PCT actively works Anna Moloney                   Ongoing         Local Resilience Forums Local Resilience Forum
Resilience                 with local partners on use of                                                work programme in place meets every 3 months.
                           Resilience Forums to test                                                    Pandemic Flu group plan Chaired       by      Local
                           emergency       preparedness                                                                         Authority, who maintain
                           (including Pandemic Flu) and                                                                         action log.
                           is implementing a programme                                                                          Pandemic Flu group
                           of work identified through                                                                           meet every 2 months,
                           planning tools.                                                                                      and minutes of meeting
                                                                                                                                disseminated       through
                                                                                                                                PCT.        A    suite   of
                                                                                                                                Pandemic       Flu    plans
                                                                                                                                produced, signed off by
                                                                                                                                Integrated Governance
                                                                                                                                February 2009.
                                                                                                                                Both     groups       multi-
                                                                                                                                agency.

HPV Campaign               Implementation       of            a Anne Rothery/           From            90% coverage               Working Group set up
                           preventive   programme            to Julie Annakin           September                                  Campaign            starts
                           reduce the incidence              of                         2008                                       September 2008.
                           cancer of the cervix                                                                                    12-13yr age group 94%
                                                                                                                                   coverage.
                                                                                                                                   17-18yrs catch up 40%.

Regional           (NW) Ensure effective and safe Anne Rothery                          Ongoing         Roll out of    new   HPV Working group meeting
Immunisation            implementation of national                                                      programme.               held 6-weekly.
Programme               vaccination and immunisation
Standards               programme.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                         75
   Development/                  Key Aim/Objective                Lead Person(s)          Target Date    Performance Measure         Reported Progress
      Topic
Regional (NW)              Ensure that national minimum Anne Rothery                    Ongoing         New training package in Ongoing
Immunisation               standards for immunisation                                                   place.
Programme                  training are met.
Standards (cont/d)
                           Ensure that an information Julie Annakin                     Ongoing         Regular communication Monthly updates to all
                           system is in place to facilitate                                             with providers.       Providers.
                           high     uptake     of    child
                           immunisations.

Improved      Palliative Expansion      and     further Pauline Sumner                  July 2008       Audit of preferred place Audit ongoing.
Care                     development of the Palliative Margaret Hayes                                   of care                  Collecting data on
                         Care Respite at Home Team to                                                                            preferred place of death
                         offer evening and night cover                                                                           /actual place of death.
                         aimed at supporting patients                                                                            Respite team now
                         and their families who wish to                                                                          recorded and all posts
                         remain at home at the end of                                                                            now substantive. 4 nights
                         life.                                                                                                   only covered for night
                                                                                                                                 sitting.

Community              PCT     Pharmacy    Needs Peter Howarth                          October 2008    Group covering PH,         New legislation being
Pharmacy         Needs Assessment document to be                                                        Pharmacy           Needs   drafted.   Requirements
Assessment             reviewed                                                                         Assessment     to     be   of an updated PNA are
                                                                                                        convened and address       being considered by the
                                                                                                        update issues.             PCT Pharmacy Officers
                                                                                                                                   Group in the context of
                                                                                                                                   the proposed changes.
                                                                                                                                   First meeting February
                                                                                                                                   2009. The PCT Pharmacy
                                                                                                                                   Steering Group which
                                                                                                                                   includes           LPC
                                                                                                                                   representation      will
                                                                                                                                   oversee the production
                                                                                                                                   of the new PNA.

NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                        76
   Development/                  Key Aim/Objective                Lead Person(s)          Target Date    Performance Measure             Reported Progress
      Topic
Operational Plan           Identifying    the    strategic Louise Roberts               In progress     Production    of    regular Action plan developed.
                           direction of commissioning.                                                  progress reports            Will   be      monitored
                                                                                                                                    through    Performance
                                                                                                                                    Accelerator in 2010.

The NHS Contract           Prepare project        plan    and Louise Roberts            In progress     Production    of    regular Produced         regular
                           monitor progress                                                             progress reports.           updates      on      NHS
                                                                                                                                    contract 08/09.     Used
                                                                                                                                    only as an internal tool,
                                                                                                                                    to monitor progress and
                                                                                                                                    ensure completion within
                                                                                                                                    timeframes.

Collaboration     with Ensure that an effective Ben Dearden                             In progress     A combined intelligence        Integrated Intelligence
Public          Health service is provided for, and in                                                  paper taken to EMT to          Project        Manager
Intelligence Team      collaboration with, the Public                                                   define a joint approach        appointed for 6 months
                       Health Intelligence Team.                                                        to linking integrated BI/PHI   to ensure Integrated
                                                                                                        with          commissioning    Intelligence Framework
                                                                                                        decisions.                     developed           and
                                                                                                                                       delivered    as     per
                                                                                                                                       WCC/CSP vision.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                            77
Seventh Domain – Public Health


  Domain Outcome: Programmes and Services are designed and delivered in collaboration with all relevant organisations and
                communities to promote and improve the health of the population served and reduce health inequalities between
                different population groups and areas


   Development/                  Key Aim/Objective                Lead Person(s)          Target Date   Performance Measure       Reported Progress
      Topic
PROVIDER DIVISION

Public Health Strategy     Ensure clients are offered Hilary Garratt/                   March 2009      Performance against the LEAN review of Health
                           appropriate                health Kathy Powys                                designated performance Improvement Service
                           improvement       support       to                                           indicators e.g. smoking undertaken . Agreement
                           reduce their risk of ill health in                                                                   reached to integrate
                           the priority areas highlighted                                                                       PCT and TMBC teams
                           by the commissioners.                                                                                to ensure maximum
                                                                                                                                effectiveness. New
                                                                                                                                models of service
                                                                                                                                delivery commenced
                                                                                                                                January
                                                                                                                                2009,designed to
                                                                                                                                deliver more
                                                                                                                                personalised service to
                                                                                                                                significantly more local
                                                                                                                                people .




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                                     78
REFERENCES

           Department of Health (1998)                    „A First Class Service – Quality in the NHS‟
                                                           DoH, 1998. London.

           Department of Health (2005)                    „Commissioning a Patient Led NHS‟
                                                          DoH, 2005, London.

           Department of Health (2006)                    „Health Reform in England: update and commissioning framework‟
                                                          DoH, 2006, London.

           Department of Health (2004)                    „Standards for Better Health‟
                                                          DoH, 2004, London.

           National Audit Office (2007)                   „Improving Quality and Safety – Progress in Implementing Clinical Governance
                                                          in Primary Care – Lessons for the new Primary Care Trusts‟.
                                                          NAO, 2007.

           Department of Health (2007)                    World Class Commissioning: Vision Summary
                                                          DoH, 2007, London.




NHS Tameside & Glossop Clinical Governance Development Plan Out-turn Report as at 31st March 2009                                        79

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:53
posted:9/7/2011
language:English
pages:80
yanyan yan yanyan yan
About