Annual Plan Progress Report – Quarter 1
R
A
G
Delivering
Quality
Improvement
The Majority of milestones are green; The amber milestones are as follows:
• To reduce towards zero avoidable community suicides where risk communication is a factor: service users on leave
and/ or in contact with crisis services.
• We are reducing towards zero all healthcare associated infections - Despite carrying out all the identified preventative
measures and improvements, the number of infections does not decline.
• We are improving access to services through introducing a single point of access for Community Services and a new
non emergency contact number “111” - Implementation challenges remain unknown as no other pilot site has moved
from a system of GP triage to the 111 system.
• We are investing in a new 80 bed Hospital and community Resource Centre In Aylesbury Buckinghamshire - Current 6
week delay due to subcontractor liquidation, Trust project team working with Kia to mitigate slippage.
Delivering
Operational
Excellence
There is one red and three amber milestones:
• Delivery of Cost Improvement Plans (RED) - Delays due to additional scrutiny/assurance processes have caused
shortfalls. In some cases initial estimates of returns have had to be revised down following detailed planning. PMO
working to accelerate projects where possible to recover delays. Mitigation schemes being scoped to cover shortfall.
• Implementation of ACE programme
• Reduce trust cancelled appointments - Baseline taken at end Q1 and targets to be agreed for delivery.
• Full implementation and use of RIO IT system across the trust – See below in ‘Getting the most out of technology’
• Maintain Governance risk rating - Actions to address the performance of both targets have been put in place. The plan
resulted in an improved performance for the CPA target but the C.diff target remains an on-going risk..
Delivering
Innovation,
Learning and
Teaching
Developing our
Business
MILESTONES RATED AS RED
SUMMARY OF PROGRESS / ACTIONS TO MITIGATE ANY SLIPPAGE
Three out of the five milestones are rated as Amber:
• Establish databases to identify research opportunities - Given a higher priority with increased collaboration with the
Trust's IT services.
• Increase patient participation in research studies - Director of R&D and colleagues in the University of Oxford,
Department of Psychiatry are working with clinical leaders and managers to improve recruitment
• Develop clinicians to leadership roles
One red and two amber milestones:
• OHFT Membership (RED) - Planning a campaign to encourage each staff member to sign up one FT member - this
would give us 6000 new members. Head of Communications to link with Deputy Director of HR workforce data issues.
• Regular communications with carers and families to encourage partnership and OHFT membership - Divisional
Champions have been identified and meeting needs to be set up asap to find out what support is required for divisions.
FT Membership banner has been designed and ordered for use at Trust events to promote membership.
• Roll out of an integrated care model across all services
Developing
Leadership,
People and
Culture
The majority of milestones are green; The amber milestones are as follows:
• Training needs analysis - To be undertaken within Q3 but progress on workforce plans will impact adversely if they are
not completed in accordance with current planning.
• New PDR/Appraisal process – Highlighted reports to Divisional Directors to action those areas where PDRs remain 'not
current'.
• Revised statutory and mandatory training process – Escalation to Divisional Directors and Executive Board, with
requirement to update action plans. Alternative training solutions enabled for high volume areas (e.g. Fire and
Equality/Diversity). Review of cancellation processes across divisions to ensure escalation to appropriate managers.
• Corporate and divisional workforce plans in place - Template design behind plan due to resourcing problems within
the Workforce Team. Project being reviewed by DHR and Deputy DHR to address slippage
Getting the
Most of
Technology
The majority of milestones are green; The amber rated milestones are as follows:
• New Mobile Working – There is capacity issues to deliver this, it has been given a high priority status.
• Embed use of RIO – Programme Board meetings have occurred, but there are service capacity issues to undertake the
activities
Using our Estate
Efficiently
All of the milestones are currently rated as green; Capital investment is being prioritised to address high risks through a
group led by the Director of Nursing with representation from all service divisions. Residual risks being robustly managed.
1.
OHFT Membership
2.
Delivery of Cost Improvement Plans
ANNUAL PLAN PROGRESS BY RAG
Number of Milestones
WORKSTREAM
Report on High Risks (Quarter 1)
RISK RISK NAME
REF
RISK MATRIX
GOV
11
5 - Very
High
OPS
05
FIN
04
Ineffective infection control management
FIN
03
RISK
OWNER
CQC
OUTCOME
Director of
Nursing and
Clinical
Standards
8
RESIDUAL RISK ACTIONS
RISK
SCORE
High
16
• Policy and guidance to be reviewed in light of new national guidance by (tbc) (Lead: tbc)
• Establishment of audit arrangements to assess compliance with MRSA screening policy by (tba) (Lead: Head of Nursing Older Adult Services)
• Peer review of individual cases looking at the RCAs and recommending actions to reduce number of cases (Lead: Director of Nursing and Clinical
Standards)
• Monitoring of quarterly trajectory and action plan mechanism with PCT (Lead: Director of Nursing and Clinical Standards)
High
Probability
• Communication and collaboration plan with GPs to be developed by (tbc) (lead: tbc)
GOV
11
GOV
13
• Out of Hours contract with OUH to be agreed and signed (Lead: Head of contracting) Contracts for microbiology services to be agreed and signed
(Lead: Head of Contracting)
FIN
07
GOV
13
Ineffective medicines management
Medical
Director
9
High
16
• Review of effectiveness of non-medical prescribing within the organisation [Source Local National Inquiry Action Plan] by Dec 12 (Lead: Medical
Director/Director of Nursing and Clinical Standards)
• Introduction of new operating procedures in prisons by (tbc) (Lead: tbc)
Medium
• Identify the technical solution that will enable Ascribe to be utilised at HMP Bullingdon and C&SH by end June 12 (Lead: Pharmacy Procurement
Manager) [Ref: 11/OHFT/19a Internal Audit, Clinical Pharmacy Support Unit - CHO transition Arrangements]
• Review the contract, and investigate alternative options through CPSU, and cost the savings possible including any early exit costs from the contract
by end Dec 12 (Lead: Chief Pharmacist) [Ref: 11/OHFT/19a Internal Audit, Clinical Pharmacy Support Unit - CHO transition Arrangements]
• All purchases of drugs and supplies should be quoted for by CPSU and external providers, and the cheapest option selected and evidenced by 1st
April 12 (Lead: Pharmacy Procurement manager) [Ref: 11/OHFT/19a Internal Audit, Clinical Pharmacy Support Unit – CHO transition Arrangements]
Low
• All budgets reviewed monthly by budget holder and finance and remedial action for variances identified and recorded by 1st April 12 (Lead: Chief
Pharmacist) [Ref: 11/OHFT/19a Internal Audit, Clinical Pharmacy Support Unit - CHO transition Arrangements]
• Medicines Management strategy to be updated by Dec 12 [Source Local National Inquiry Action Plan] (lead: Chief Pharmacist) Review of pharmacy
input to clinical areas by Oct 12 [Source Local National Inquiry Action Plan] (Lead: Chief Pharmacist)
1 - Very
Low
• E-learning package for medicines management to be established by (tbc) (Lead: Chief Pharmacist) Training education and support for prescribers to
be reviewed by Dec 12 [Source Local National Inquiry Action Plan] (Lead: Chief Pharmacist).
• Licence review due 2011 (Lead: OPS Commercial Development Manager)
1 - Very
Low
Low
Medium
High
5 - Very
High
OPS
05
Facilities are not fit for purpose and
therefore do not support effective service
delivery
Chief
Operating
Officer
8
High
20
• Issue of capital to transfer with community estate to be raised with FTN (Lead : Chief Executive) Business Case for transfer of community services
estate including due diligence (Lead: Director of Finance) Engagement of Clinical Commissioning Groups post PCTs to confirm and protect revenue
in Buckinghamshire to support Manor House development (Director of Finance)
• Clear evidence of checks should be reviewed and documented by the Project Board at every stage and every meeting. [Ref Internal Audit
10/OBMH/21 (Lead: Interim Director of Estates)
Impact
• Governance principles should be adhered to at all times, and regular reviews undertaken to ensure any breaches are identified and escalated to the
Board of Directors, or its nominated committee. Furthermore, the recording of minutes for all committees and groups should be standardised and
consistent. [Ref Internal Audit 10/OBMH/21] (Lead: Interim Director of Estates)
• All procurement should be reviewed on the project to ensure it is appropriate and correctly authorised, decisions as to why consultants were
selected recorded, and to ensure that competition requirements have not been breached [Ref Internal Audit 10/OBMH/21] (Lead: Interim Director of
Estates)
• Calculation for single sex breaches to be revised to meet central guidance (Lead: Director of Nursing) Review of suitability of minimum build
standards for fencing by (tbc) (Lead: tbc)
FIN
03
Non- delivery of cost improvement plans
could cause the trust to fail in the delivery
of its financial plan which could lead to
additional scrutiny and intervention by
Monitor and a shortfall in cash for the
trust’s Capital Programme
Director of
Finance
-
High
25
• Business case for the realignment of Improvement and Innovation programme and Cost Improvement/benefit realisation plan (Lead: Head of
Strategy and Programmes)
• Development and approval of 3 year savings plan to meet savings target as part of Annual Plan to be submitted to Monitor's deadline for Annual
Plan (Lead: Head of Strategy and Programmes)
• Delivery of 11/12 cost improvements by March 12 (Lead: Director of Finance)
• Executive Board to consider how improvement and transformation resources could be focused on delivering and aligning benefits to form part of
the work on next year's Annual Plan and the delivery of CIPs by End February2012 (Lead: CEO)
FIN
07
The payment of salaries, allowances,
variable pay, expenses, deductions is not
properly managed leading to salary or
expenses under/over payments and
resulting in pecuniary loss and/or staff
dissatisfaction
Director of
Human
Resources
-
High
16
• Review of reimbursement criteria to be completed by end April 2012 (Lead: Payroll Manager) [Ref: Internal Audit report 11/OH/5 Payroll] Review of
sanctions to be enforced against non compliance with Trust payment guidelines (Lead: Payroll Manager) [Ref: Internal Audit report 11/OH/5 Payroll]
A resourced plan for full roll out of e-expenses using Trust's project plan methodology to be agreed by Sept 2012 (Lead: Payroll Manager)
[Ref:Internal Audit report 11/OH/19C
• E-expenses - On-going Technological solution required for all HR forms to be scoped and agreed following standardisation of forms (Lead: ESR
Programme Manager)
• Contract for long term solution for payroll to be executed prior to the commencement of the contract (Lead: Payroll Manager) {Ref: Internal Audit
reports 11/OH/5 Payroll: 11/OH/10B Payroll provider]
• Business Case for long term payroll solution to be approved (Lead: ESR Programme Manager) Sept 11
• Legal advise to be sought to ensure that appointment of interim provider does not go against legal requirements relating to procurement (Director
of HR)
• Appointment of Interim Provider for maximum of 12 months to allow completion of formal tender process (Director of HR) (In Place)
Author
Usmaan Rahman, Strategy & Business Planning Manager
Lead Executive Director: Mike McEnaney, Director of Finance
• Payroll long term solution to be in place by Jan 13 (Director of HR)
FIN
04
Stated government intent in the Health and
Social Care Bill 2011 to increase
competition in the provision of healthcare
services could lead to loss of existing core
business and therefore a loss of
contribution to overhead and fixed costs
and loss of margin; new business
opportunities not realised (won) that
compliment our core business and add
contribution; erosion of competitive edge
preventing the trust substituting additional
contribution and margin for CIPs; working
without a national tariff and under block
contract arrangements the Trust is forced to
compete on price in addition to quality and
to ensure core business is retained has to
reduce price and therefore
contribution/margin
Director of
Finance
-
High
20
• Delivery of cost improvement plan by March 2012 (Lead: Director of Finance) Business planning templates to be completed by 15th March 2012
(Lead: Divisional/Corporate Directors)
• Consolidation of business plans into the Annual Plan for presentation to the May Members Council and Board of Directors for submission to
Monitor by end of May 12 (Lead: Head of Strategy and Programmes)
• Information review and Data warehouse consolidation complete June 12 (tbc) (Lead: Interim Head of Information and Business Intelligence)