Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Quality and Delivery
Framework
Performance Report
Quarter 2 2014/15
Author: Public Health Wales
Date: 10 November 2014
Version: 1
Distribution:

Public Health Wales Board

Welsh Government

Public Health Wales Intranet and Internet
Purpose and Summary of Document:
The purpose of this performance report is to provide the Public Health
Wales Board and the Welsh Government with an update on performance,
using the Public Health Wales’ Quality and Delivery Framework. For
2014/15, this framework has been expanded to include:

all performance indicators contained in the Public Health Wales
Operational Plan 2014/15

a summary of progress in the completion of the tasks specified in
the Public Health Wales Operational Plan 2014/15
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Public Health Wales
1
Quality and Delivery Framework
Performance Report – Q2 2014/15
Performance indicators
This section presents numerical performance indicators relating to existing
Public Health Wales programmes and services and to some of our key internal
enablers.
Most indicators are reported against targets. In these cases, the performance
achieved is also colour coded using the following traffic light system:
Green
Performance meets target
Amber
Performance is within 10% of target value
Red
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Performance is more that 10% below target
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Overall performance of all NHS Wales smoking cessation
services (Tier 1 targets)
Target
Actual
Q1 14/15
(See Operational Plan p34)
Smokers treated by all smoking cessation services (of which Stop Smoking
Wales aims to provide service for 2.8%)
>=5%
2.14%
Carbon monoxide (CO) validated quit rate at four weeks
>=40%
33.84%
Stop Smoking Wales performance
Target
Actual
(See Operational Plan pp34-35)
Q1 14/15
Note- Data presented below is for Q1. Q2 data will not be available until 25 November 2014.
Latest monthly data is presented on the next page.
Number of smokers treated
1506 (Q1)
1483
Self reported quit rate at four weeks
>=50%
51.7%
CO validated quit rate at four weeks
>=40%
37.7%
52 week success rate (of four week quitters)
>=15%
28.2%
Client satisfaction rate (% of responses)
>=80%
96.1%
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Performance of Stop Smoking Wales- September 2014 (Monthly data provided as Q2 data not available)
(In 2014/15 SSW was allocated a target of 2.8% as part of overall Tier 1 5% target)
Health Board
/Trust
Clients that became a treated
smokers in this month
Oct-14
% of clients that were CO
validated as quit in this
month
Year to date
Target
Actual
Target
Actual
1391*
616
5675
Abertawe Bro
Morgannwg
257
184
Aneurin Bevan
268
Betsi Cadwaladr
SSW capacity of appointments
available in this month
Oct-14
Oct-14
Target
Oct-14
Target
Actual
3649
47.3%
2960
2748
12077
16677
1034
924
38.3%
547
531
2200
2716
97
1123
602
58.4%
570
495
2391
2651
290
109
1250
800
48.3%
617
437
2660
2881
Cardiff and Vale
189
79
642
403
45.8%
402
397
1365
2827
Cwm Taf
164
54
674
330
43.9%
349
305
1435
2089
Hywel Dda
156
75
717
471
47.1%
332
212
1526
2301
67
18
235
119
60.0%
143
253
500
669
Wales
Powys
Target
Year to date
>=40%
*Note 2.8% equivalent total number of smokers annual target profiled through the year with a rising trajectory.
Actions to be undertaken to improve performance
In an attempt to increase referrals to the service, a detailed action plan that details a number of specific actions that will be undertaken.
These include
Production of joint action plans with health boards with a focus on increasing numbers who access the service.

Development of an agreement to outline roles and responsibilities for Public Health Wales and health boards.

Implemented a mass media campaign across Wales to highlight the service and recruit smokers. Phase 2 of which will commence in
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
January 2015.

Development of a web based on line service as a option for quitting – with a view to incorporating access to pharmacotherapy and co
monitoring

Introduce 2 mobile outreach units that will target communities known to have high smoking prevalence.

The introduction of high street drop in units aimed at recruiting smokers in a similar way to the mobile unit but using shops in key
communities with high foot fall

A relocation of staff to integrate with LPHTs to improve working relationships with a view to increasing referrals.

Stakeholder events x 2 were held to explore the issues with SSW and the following actions and projects are being developed to take
account of feedback at these events. Events included staff and wider stakeholders.

Developing a more flexible workforce is currently underway. This will include more flexibility in opening hours to include weekends.
Staff to develop other skills in terms of active recruitment – workforce development plan being developed with development areas
prioritised with a view to undertaking training as a matter of urgency.

Recruitment to vacant posts and establishing a bank staff to support delivery of service as required- 17 bank staff have been
recruited and are in the process of boarding between the 3 November 2014 and 1 December 2014. 2.6 WTE of vacant posts has also
been recruited.

Telemarketing employers to actively recruiting smokers from workplaces

Development of a web based on line service as a option for quitting – with a view to incorporating access to pharmacotherapy and co
monitoring

Working with pharmacists to develop and implement a variation of the current community pharmacy level 2 model with the addition
of CO validation for those who access telephone or online support. It is anticipated that this will also improve the clients journey as
it will ease access to NRT.

Potential to work with primary care to act as an agent on behalf of GP practice by actively phoning known smokers from QoF data.
This is currently being explored.

Currently exploring the development of an Optical and Dental referral scheme to recruit via this group

Strengthen communication links with both internal and external stake holders
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Stop Smoking Wales Performance Trend
Cumulative Treated Smokers- Wales
18000
16000
14000
12000
10000
Cumulative Target
8000
Actual Cumulative
6000
4000
2000
0
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
Monthly Treated Smokers- Wales
3000
2500
2000
Actual
1500
Target
1000
500
0
April
May
June
July
August
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Sept
Oct
Nov
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Dec
Jan
Feb
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March
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
ASSIST performance
Q2 Target
(See Operational Plan p35)
Number of secondary schools targeted by ASSIST
N/A
Actual
Q1 14/15
Q2 14/15
15 (Q1 Target-10-15)
N/A*
*No performance data available due to programme running during school term time only
Healthy Working Wales performance
Q2 Target
(See Operational Plan p51)
Actual
Q1 14/15
Q2 14/15
Organisations completing a Corporate Health Standard mock assessment
5
7 (Q1 Target-9)
6
Private sector organisations completing a mock assessment
1
5
4
Organisations completing a full assessment
5
5 (Q1 Target-9)
6
Private sector organisations completing a full assessment
1
1
4
Organisations achieving a Small Workplace Health Award
30
32 (Q1 Target-31)
21
150
170 (Q1 Target-175)
155
Number of Workboost interventions delivered
Actions to be undertaken to improve performance

Recruiting an additional practitioner to encourage and support businesses through the assessment process.

Additional resource also recruited to make contact with businesses. This will commence on the 01 November 2014.
Mental Health First Aid
Q2 Target
(See Operational Plan p51)
Number of trainees
400
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Actual
Q1 14/15
Q2 14/15
305
475
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Alcohol Brief Intervention training performance
Q2 Target
(See Operational Plan p52)
People trained to deliver alcohol brief interventions
Training sessions delivered
National Children’s Obesity Referral Programme
Actual
Q1 14/15
Q2 14/15
25
490
436
4
40
25
Q2 Target
(See Operational Plan p52)
Training programmes delivered
N/A
Actual
Q1 14/15
Q2 14/15
8 (Q1 Target-16)
N/A*
*No performance data available due to programme running during school term time only
National Exercise Referral Scheme performance
Q2 Target
(See Operational Plan p52)
Actual
Q1 14/15
Q2 14/15
Number of referrals
5339
7,111
7507
Number of consultations
5339
6,698
6869
Take up
4004
3,845
4037
Completion of 16 week intervention
1799
2,180
1956
899
1,142
1001
52 week retention
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Microbiology performance
Target
Actual
(See Operational Plan p116)
Q1 14/15
Q2 14/15
Full
Full
Full
EQA performance – bacteriology
>=95%
93.8%
99.5%
EQA performance – virology
>=95%
100%
96.8%
Turnaround time compliance – bacteriology
>=95%
95.5%*
94.5%
Turnaround time compliance – virology
>=95%
89.7%*
89.4%
Turnaround time compliance – urgent samples
>=95%
Non processed samples – bacteriology/virology
TBC
2.2%/0.5%**
1.7%/0.5%
Number of samples processed – bacteriology
N/A
266,430**
265,770
Number of samples processed – virology
N/A
105,411**
97,952
Microbiology - CPA accreditation status
Reported annually
*Cardiff data currently only available to 16 June, due to implementation of new Laboratory Information Management System (LIMS).
**Cardiff data currently extrapolated for June (from April and May), due to implementation of new LIMS.
Actions to be undertaken to improve performance
Turnaround time compliance - bacteriology- Delays in processing and reporting of samples can also be attributed to implementation of
Trak into the Cardiff laboratory.
Turn around compliance- virology - data was not available for some virology tests in a number of laboratories due to coding changes
made during implementation of Trak - the new computer system. Delays in processing and reporting of samples can also be attributed to
implementation of Trak into the Cardiff laboratory.
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Screening programme performance- Quarter 1
Standard
Q1 Target
Actual
(See Operational Plan pp125-127)
Q1 14/15
Note- Data presented is for Q1. Q2 data will not be available until 25 November 2014.
Latest monthly data is presented on the next page.
Breast screening uptake
>=70%
>=71%
71.6%
Full
Full
Full
Abdominal aortic aneurysm screening uptake
>=80%
>=71%
71.8%
Newborn hearing screening percentage offered screening
>=99%
100%
100%
Newborn hearing screening percentage entering screening
programme
>=95%
>=99%
99.6%
Newborn bloodspot screening uptake (newborn babies)
>=99%
>=99%
Data not yet available
Breast screening: normal results sent within two weeks of screen
>=90%
>=80%
79.0%
Breast screening: assessment appointments within three weeks of
screen
>=90%
>=33%
24.1%
Breast screening: % women invited within 36 months previous
screen
>=90%
>=10%
8.6%
Bowel screening waiting times for screening test results
>=95%
>=90%
95.6%
Bowel screening waiting time for colonoscopy
>=95%
>=11%
18.0%
Cervical screening lab turnaround times: within three weeks
100%
>=55%
43.7%
Cervical screening waits for results: within four weeks
100%
>=58%
43.6%
Laboratory CPA accreditation
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Screening Programme Performance- Monthly
Actual
Standard
Target Q3
Aug 2014
Sep 2014
Oct
2014
>= 95%
98.0
94.4
96.7%
>=90%
>= 40%
26.5
31.2
34.7%
CSW-003A: Laboratory Turnaround Time for Gynae
Cytology Test Results (3 weeks)
100%
>=75%
41.5
50.1
Not
available
Cervical
Screening Wales
CSW-004A: Waiting time from sample being taken to
screening test result being sent (4 weeks)
100%
>=78%
45.5
49.8
72.2%
Cervical
Screening Wales
CSW-005A: Waiting Time for Colposcopy
Appointment - All CSW Direct Referrals with abnormal
cytology (8 weeks)
>= 90%
N/A
97.6
89.7%
Not
available
Bowel Screening
Wales
BSW-006A: Waiting Time for Screening Test Results
(result letters issued within 7 days of receipt of test
kit in lab)
>= 95%
>= 95%
99.5
99.6
99.7%
Bowel Screening
Wales
BSW-007: Waiting Time for Colonoscopy
>= 95%
N/A
58.1%
60.3%
81.2%
Welsh Abdominal
Aortic Aneurysm
Screening
Programme
AAA-003: AAA Surveillance Uptake (Medium AAA
attending between 11 to 15 weeks, Small AAA
attending between 50 to 56 weeks of a previous
successful scan and receive a conclusive result)
>= 90%
N/A
84.2
88.9
Not
available
Newborn Hearing
Screening Wales
NBH-004A: Well babies - the percentage of babies
who complete the screening programme within 4
weeks
>= 90%
N/A
98.9
98.6%
Not
available
Newborn Hearing
Screening Wales
NBH-007: Those babies who complete assessment
procedure by three months of age
>= 80%
N/A
87.1%
84.8%
86.5%
Screening
Programme
Report Description
Breast Test Wales
BTW-005: Normal results sent within 2 weeks of
screen
>=90%
Breast Test Wales
BTW-006A: Assessment invitations given within 3
weeks of screen
Cervical
Screening Wales
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Breast Screening: Normal Results Sent Within 2 Weeks
of Screen
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
60.0%
55.0%
50.0%
Breast Screening: Assessment Appointments Within 3
Weeks of Screen
Actual
Target
Actual
Target
Cervical Screening: Test Results Issued Within 4 Weeks
Cervical Screening: Laboratory Turnaround of Results
Within 3 Weeks
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
Actual
40.0%
Target
30.0%
Actual
Target
20.0%
10.0%
0.0%
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Cervical Screening: Colposcopy Within 8 Weeks of Direct
Referral
AAA Screening: Surveillance Uptake
100.0%
95.0%
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
60.0%
55.0%
50.0%
90.0%
85.0%
80.0%
75.0%
Actual
Actual
70.0%
Target
65.0%
60.0%
55.0%
50.0%
Bowel Screening: Colonoscopy/Flexi-Sig Within 4 Weeks
of SSP Appointment
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Bowel Screening: Results Issued Within 7 Days of Lab
Receipt
Actual
Target
Date: 10/11/14
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
60.0%
55.0%
50.0%
Version: 1
Actual
Target
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Newborn Hearing Screening: Well Babies Completing
Screening Within 4 Weeks
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Newborn Hearing Screening: Assessment Completed by
3 Months of Age
Actual
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Actual
Actions to be undertaken to improve performance
BTW-005- This target was not met in Q1, correction is expected in Q2, the in month figures for July and August are 97.8% and 98%
respectively. The failure to achieve this target in Q1 was secondary to workforce challenges.
BTW-006A- This standard remains challenging and is a key focus of the programme, the whole pathway of assessment in currently under
review. The following actions have been undertaken
A facilitated workshop has been held with key staff

The current pathway has been mapped in partnership with the 1000 lives team

Summary actions have been agreed

The actions will be managed by a sub group chaired by the Divisional Business Manager in conjunction with the Head of Programme
for Breast Test Wales.

Key work streams will focus on reducing the number of cancelled clinics and in developing a sustainable workforce in the medium
term.
CSW-003A and CSW-004A- The following actions have been undertaken
Currently reviewing service and developing a workforce model (including skill mix) to ensure laboratory staffing is able to support
services during implementation of cervical screening recovery plan and HPV test of cure implementation

Enforce policy for refusing ‘out of scope’ samples and ensure GPs and sample takers know the correct pathway for symptomatic
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
patients

Continue work with NWIS to develop mechanism for electronic results issuing to participants and primary care

Currently reviewing transport infrastructure to minimise delays in transporting samples to main processing laboratories and explore
options to develop model to support other screening programmes

Reconfiguring administration functions to ensure consistency in support provided to laboratories, thereby developing the
infrastructure to support a reduction in result turnaround times

Implement 28 day wait for results for cytology samples and undertake local intervention in health boards where performance is
outside standard and undertake additional monthly contract performance monitoring
AAA-003- The following actions have been undertaken
Developing ‘easy read’ resources for participants with learning disabilities, including ‘key messages’ in an accessible format, a new
AAA pack and a revised bowel screening pack
BSW- 007- The following actions have been undertaken
Work with health boards with longest waits to improve provision of service to commissioned levels, including:
o
Continual monitoring of service provision and contract performance
o
Performance review meetings with health board service managers to monitor effectiveness of recovery plans (monthly where
performance is worst, otherwise quarterly)
o
Provide health board cancer leads with monthly monitoring information
o
Targeted work with ABMU, Cwm Taf and Aneurin Bevan
o
Continuous review of activity, adjusting patient flow to available capacity
o
Use of all available spare capacity and continued facilitation of travelling colonoscopists where available

Plan for alternative provision where health boards are unable to provide service e.g. commission service from England private
providers

Support the implementation of the Welsh Government Endoscopy Action Plan, to improve waiting times for colonoscopy
Note- Data presented above is monthly data. Q2 data is not yet available. Available on 17 November 2014
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Healthcare associated infections
Q2 Target
Actual
(See Operational Plan p141)
Clostridium difficile rate (cases)
MRSA rate (cases)
Q1 14/15
Q2 14/15
<=242
322
360
<=20
43
36
Performance trends
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
44
8.0 6.92
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
5
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
100.089.24
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
12 month rolling rate of MRSA bacteraemia/100,000 population
12 month rolling rate of C. difficile/100,000 population
Actions to be undertaken to improve performance

Revising the monthly health board HCAI dashboard to reflect the new targets – the new dashboards were introduced in August 2014 so
that health boards are absolutely clear on their monthly progress against the target;

Regularly reviewing the health board surveillance data, notifying organisations of any unusual activity and offering support to help
health boards deal with it – a number of health boards have been contacted by Public Health Wales since April and a variety of support
has been provided;

Support the benchmarking of progress against targets through the provision of data at bi-monthly HCAI meetings –C. difficile and
MRSA bacteraemia data has been made a standing item for discussion at the bimonthly Public Health Wales HCAI teleconference.
Graphs are provided that plot all health boards and major acute hospitals on the same scale, making it clear to all health boards their
progress compared to others;

Map infection rates and antimicrobial usage for both primary and secondary care – the first map was issued in August, allowing health
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
boards to visualise their C. difficile rates by place of diagnosis in both primary and secondary care, alongside rates of prescribing of
total antibacterials, the “4C” antibiotics and proton pump inhibitors in primary care. Additional data will be included in the next map
planned for the end of October.

Provide ongoing proactive and ad hoc advice and support to health boards in relation to infection prevention and control, prescribing
and antimicrobial resistance;

Undertake a series of meetings to discuss health board action plans aimed at reducing HCAIs and agree bespoke support to be
provided through development of joint action plans – to date only one of these meetings has been held, but others are timetabled for
between November and early January;

Deliver bespoke support, including the analysis of data, identified through discussions with health boards;

Establish a steering group to oversee the development of an Antimicrobial Resistance Delivery Plan for Wales – a draft delivery plan
has been submitted to Welsh Government.
Uptake of all scheduled childhood vaccinations at age 4
Note- Q2 data unavailable- Available December 2014
Area
Target
Actual Q1 14/15
Wales
86.1%
Abertawe Bro Morgannwg
85.3%
Aneurin Bevan
82.7%
Betsi Cadwaladr
Cardiff and Vale
90.3%
>=95%
83.2%
Cwm Taf
90.4%
Hywel Dda
85.7%
Powys
86.1%
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Quality and Delivery Framework
Performance Report – Q2 2014/15
Childhood Vaccination Rate Performance Trend
Actions to be undertaken to improve performance

Guidance provided to health boards on where to target resources to meet it, in particular in increasing the pre-school uptake of MMR
and 4 in 1 vaccine (tetanus, diphtheria polio and pertussis).

Improvements in uptake of these vaccines given at 3y4m will take around one year to be apparent in improvements in the Tier 1
target, which is measured at the 4th birthday.
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Quality and Delivery Framework
Performance Report – Q2 2014/15
Influenza vaccination rates at 26/10/14
Health Board
/Trust
Influenza vaccination
uptake among the over
65s
Target
Influenza vaccination
uptake among under
65s in high risk groups
Actual
Target
Actual
Influenza vaccination
uptake among pregnant
women
Target
Actual
Wales
45.9%
27.8%
25.2%
Abertawe Bro
Morgannwg
40.6%
23.5%
20.9%
Aneurin Bevan
49.2%
31.5%
24.7%
Betsi Cadwaladr
>=75%
49.2%
>=75%
29.3%
>=75%
31.3%
Cardiff and Vale
42.5%
26.0%
23.2%
Cwm Taf
47.6%
30.4%
23.9%
Hywel Dda
43.6%
25.9%
22.5%
Powys
46.9%
27.9%
23.9%
Influenza vaccination
uptake among
healthcare workers
Target
Actual
>=50%
Data
expected to
be available
from mid
November
2014
Actions to be undertaken to improve performance

Public Health Wales takes a ‘whole systems’ approach to improving immunisation uptake, leading, supporting and facilitating work
with partners from policy to practice level to achieve incremental improvements in immunisation programmes. Partners include other
UK PH agencies, WG policy leads, NHS Employers, professional organisations, WLGA, HBs Immunisation Coordinators, GP clusters
and individual GP practices.

Training is a key plank of delivery, as is providing clinical guidance either directly or online.

A comprehensive communications strategy has been developed with partners which has increased the public and professional profile
of flu immunisation, including working with voluntary patient groups.

Comprehensive data on outcomes is fed back at national, HB, LA and practice level regularly, with accessibility recently enhances
through the development of new software to support the IVOR reporting database.
Date: 10/11/14
Version: 1
Page: 19 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Enablers
Q2 Target
(See Operational Plan p172, p182 & p198)
Actual
Q1 14/15
Percentage of non medical staff undertaking PADR in past 12 months
Percentage of medical staff undertaking appraisal in past 12 months
>=70%
Q2 14/15
July 2014-77%*
by end Q2
100%
91%
100%
<=3.25%
3.4%
3.54%**
N/A
13
16
100%
93%
100%
Number of serious untoward incidents (SUIs) reported
N/A
0
0
SUI investigations completed within target timescales
100%
N/A
N/A
Sickness absence rate
Number of written concerns/complaints received
Written concerns/complaints responded to within target
Percentage of programmes/services with a method of capturing service
user experience data
Reported annually
Percentage of service users asked for feedback
Use of social media to engage with service users
* Survey undertaken in July 2014 indicated 77% (429 of 555) of respondents had undertaken PADR
**Figures as at the 15th October 2014 extracted from ESR. Figure is likely to increase following update of sickness absence from pay cards
Date: 10/11/14
Version: 1
Page: 20 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
2
Summary of progress in the completion of the
actions specified in the Public Health Wales
Operational Plan 2014/15
2.1
Introduction
The Public Health Wales Operational Plan 2014/15 contains 810 specific
actions to be undertaken during the year. Of these, 410 were either scheduled
to be completed by the end of the second quarter (Q2) or involved activity
taking place in Q2.
Progress against each of these actions has been assessed as at the end of Q2
and colour coded using the following traffic light system:
Green
Action completed (or, where the action runs
across multiple quarters, is on schedule)
Amber
Action not completed (or, where the actions
runs across multiple quarters, is behind
schedule), and it is expected that it will be
‘Green’ by the end of the next quarter
Red
Action not completed (or, where the action
runs across multiple quarters, is behind
schedule), and it is not expected to be ‘Green’
by the end of the next quarter
A summary of progress is presented below, including brief exception
reports for each action coded ‘Amber’ or ‘Red’. The full ‘action by
action’ assessment is also available, on request.
Date: 10/11/14
Version: 1
Page: 21 of 47
Public Health Wales
2.2
Quality and Delivery Framework
Performance Report – Q2 2014/15
Summary of progress
Entire Operational Plan
14
85
311
Health improvement
8
20
106
Ref #
Action
2
Develop and agree system-wide health improvement priorities by engaging
our stakeholders
2.1
Develop a communications
strategy informed by
stakeholder mapping to
support effective ongoing
stakeholder engagement,
reflecting the Public Health
Wales Service user Experience
Framework
Date: 10/11/14
Status
Red
Version: 1
Notes
Competing demands and limited
capacity within Directorate has
resulted in this not progressing as
anticipated. Will be addressed by
newly recruited fixed term post in
Health and Healthcare Improvement
division to end March 2015
Page: 22 of 47
Public Health Wales
2.3
Hold a launch event for the
Public Health Alliance
Quality and Delivery Framework
Performance Report – Q2 2014/15
Red
Competing demands and limited
capacity within Directorate has
resulted in this not progressing as
anticipated. Dialogue to date with
Alliance membership has
demonstrated desire for the workplace
to be the focus for improvement
activity. Optimistic that there will be
an expansion in workplace health
programme.
Red
Competing demands and limited
capacity within Directorate has
resulted in this not progressing as
anticipated. Dialogue to date with
Alliance membership has
demonstrated desire for the workplace
to be the focus for improvement
activity. Optimistic that there will be
an expansion in workplace health
programme.
2.4
Deliver joint development
sessions with Alliance
members
3
Deliver smoking prevention and cessation services, comparable with the
best in the world
E-cigarettes
3.35
Support the development of a
harm reduction/smoking
cessation protocol that will
enable Stop Smoking Wales to
provide support to clients using
e-cigarettes in their attempt to
quit, but with careful
consideration of our position
statement and concerns
outlined in the Public Health
Bill
6
Continue to deliver other agreed health improvement programmes
Red
Work stream lead has not been able to
progress work to develop protocol due
to focus on achieving tier 1 target.
Development of this protocol needs to
be informed by public health positions
from across the UK.
Engage with partners to raise awareness of Healthy Working Wales,
workplace health and the health benefits of work
6.28
Hold three meetings of the
Healthy Working Wales
Stakeholder board
Date: 10/11/14
Red
Version: 1
Q2 meeting stood down. 2 meetings
are scheduled for remainder of year; 1
in Q3 & 1 in Q4 rest of the year.
Page: 23 of 47
Public Health Wales
8
Quality and Delivery Framework
Performance Report – Q2 2014/15
Take action to improve mental health
NHS and local authorities to act as exemplar employers providing mentally
healthy workplaces in their support to staff and tackling stigma and
discrimination in their service delivery
8.14
Support the use of ‘5 Ways to
Wellbeing’ as a resource for
staff wellbeing within Public
Health Wales
Red
As at end of Q2, a number of
workplace mental health and wellbeing
initiatives have been identified for
consideration by the T&F group to
commence. This group has not met to
date however is due to meet in
November.
Ensure that service users of all ages and their families and carers are fully
involved in service development
8.16
Work with Mental Health Action
Wales (MHAW) to provide
support for service users and
carers involved in national and
local partnership boards
Red
Welsh Government not continuing to
support with this work MHAW
8.17
Establish quarterly meetings
with mental health service user
development officers as part of
MHAW
Red
Welsh Government not continuing to
support with this work MHAW
1
Implement Transforming Health Improvement in Wales, in partnership
with communities and partners from all sectors
A draft Communication and
Engagement Strategy is in place and is
being further refined following
revisions to the THIW Programme
definition. A slight delay has also been
caused by a change in personnel in Q2
and a focus on two immediate
communications priorities: a large
stakeholder event to initiate the
Collaboratives process, and the
commissioning of Focus Groups.
1.4
Develop a communication plan
to support ongoing
communication, both internally
and to wider stakeholders,
highlighting the direction and
progress of Transforming
Health Improvement in Wales
3
Deliver smoking prevention and cessation services, comparable with the
best in the world
Amber
Joint working arrangements
3.4
Develop and implement a
signed written agreement
between Public Health Wales
and health boards, outlining an
agreed set of principles to
which each organisation agrees
to work with a view to
improving uptake of smoking
cessation services provided by
Stop Smoking Wales
Date: 10/11/14
Amber
Version: 1
Discussions have taken place,
following this a report has been
forwarded to the representative
Page: 24 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
3.5
Work with directors of public
health to develop joint annual
action plans to increase
referrals to Stop Smoking
Wales, enabling the service to
treat 16,150 smokers annually
from 2014/15
Amber
Work is continuing and action plans
are in place in some areas
3.6
Develop and agree objectives
within a joint Public Health
Wales/health board annual
action plan, aimed at
improving uptake of smoking
cessation in line with the
trajectory produced by Stop
Smoking Wales. Objectives will
include joint actions on
targeting groups with
increased prevalence
Amber
Work is continuing and action plans
are in place in some areas
3.7
Implement the seven joint
annual action plans,
monitoring performance
against the projected
improvement and agreeing any
necessary mitigating action,
through monthly performance
meetings within each health
board
Amber
Work is continuing and action plans
are in place in some areas
Explore the feasibility of providing online and/or text/app based booking
systems for clients wishing to access Stop Smoking Wales
3.28
Work with the database
provider to further develop
facilities, including online
booking, text messaging of
appointment reminders and
motivational messages
Amber
Work is continuing with the database
provider to resolve issues that fail to
comply with the specification
Reduce the number of pregnancies exposed to tobacco smoke
3.45
Develop improvement
programme for roll out of
learning to health boards from
MAMMS to increase
implementation of NICE
recommendations on smoking
in pregnancy
Date: 10/11/14
Amber
Version: 1
Progressing action not possible due to
Transforming Health Improvement
Programme having to be prioritised
resulting in limited staff capacity
during Q1 and Q2. This will be
completed in Q3.
Page: 25 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Develop population level early years surveillance system
Staffing and data processing issues
have impacted on the timescales of
this work. Remedial action includes
Observatory staff working under a
honorary contract with the Informatics
services to access and process the raw
data in advance of analysis and a
revised timetable has been developed
and shared with Heads of Midwifery,
heads of Information, Directors of
Public Health and Welsh Government.
3.48
Work with NWIS and the Welsh
Government to determine the
medium and longer term plans
for mandating the collection of
the maternity data and most
appropriate home for the
dataset
4
Design, develop and implement interventions in the early years
Amber
Ensure early years work stream structure is fit for purpose
4.2
Develop overarching
stakeholder engagement plan
for early years programme
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2 resulting in limited team capacity.
Revised deadlines to be agreed.
Supporting parents in making healthy choices in the early years
4.11
Establish project to develop
options for the future delivery
of parent information and
support
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2 leading to limited staff capacity,
revised deadlines being agreed.
4.12
Review alternative parent
information resources and
current practice in Wales
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2 leading to limited staff capacity,
revised deadlines being agreed.
5
Design, develop and implement Over 50s Healthchecks (Add to Your Life)
Engage with Communities First officials and monitor progress in recruiting
health workers from allocated areas, to support their participation in Brief
Intervention training and Add to Your Life
5.6
Hold four workshops/learning
events around Wales
Amber
Workshops delivered in Q1. Those
planned for Q2 now to take place in Q3
(in October 2014). Timetable set by
WCVA and Welsh Government
Determine mechanisms for inviting eligible people to access Add to Your
Life
5.20
Initiate active invitation
process and monitor uptake as
a result of invitations
6
Continue to deliver other agreed health improvement programmes
Amber
Delays in procurement mean that
invitations being issued from 10th
October
Welsh Network of Healthy Schools Schemes
Date: 10/11/14
Version: 1
Page: 26 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Ensure the Healthy Schools scheme effectively supports the delivery of
local and national public health priorities
6.1
Establish steering
group/advisory board to guide
strategic direction with
membership from key
stakeholders
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2 resulting in limited staff capacity.
Revised deadlines being agreed.
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2 leading to limited staff capacity,
revised deadlines being agreed.
Data collection and monitoring
6.10
Revise current database to
ensure that Public Health
Wales, directors of public
health and key stakeholders
have access to information
Mental Health First Aid
Improve resilience of children and young people
6.54
Work with Mind Cymru to
support the Youth Mental
Health First Aid (YMHFA)
Scheme to the end of the
contract period.
Amber
No further development of youth MHFA
as the contract will end in November.
Improve resilience for adults and older adults.
6.55
Work with Mind Cymru to
support the Mental Health First
Aid (MHFA) Scheme to the end
of the contract period.
7
Take action targeted at obesity
Amber
No further development of youth MHFA
as the contract will end in November.
Work with key stakeholders to agree an evaluation framework and core
indicators for obesity interventions in Wales.
7.1
Produce scoping document and
project plan
Amber
Transforming Health Improvement
Programme prioritised during Q1 and
Q2, revised deadlines to be agreed.
Develop access criteria and service specification for level 3 obesity services
for children in Wales
7.5
Produce scoping document and
project plan
8
Take action to improve mental health
Date: 10/11/14
Amber
Version: 1
Transforming Health Improvement
Programme prioritised during Q1 and
Q2, revised deadlines to be agreed.
Page: 27 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Ensure that the appropriate infrastructure is in place to measure progress
in delivering the key actions of Together for Mental Health
8.30
Deliver and facilitate four
national mental health leaders
collaborative events and
support the national groups for
clinical leaders and general
managers
Amber
Support the CAMHS (and ED)
national commissioning group
and report to the CAMHS and
OPMHS Delivery Assurance
Groups
Delayed due to long term staff
sickness. Other 1000 Lives staff will
pick up this work.
This has been allocated dedicated
support to action and will be
completed in Q3.
Healthcare Improvement
4
10
53
Ref #
Action
Status
Notes
9
Identify and act on priorities for service improvement, in collaboration with
NHS Wales
With partners, support, coordinate and lead the adoption of prudent
healthcare principles across NHS Wales
9.1
Establish a programme board
within Public Health Wales to
coordinate the corporate
programme across all of our
functions to support prudent
healthcare
9.2
Engage with our partners to
establish a prudent
healthcare framework to
bring together a coherent
approach to embedding
prudent healthcare across
NHS Wales
Date: 10/11/14
Red
Red
Version: 1
This is currently under consideration
following discussions with Welsh
Government concerning our respective
roles
This is currently under consideration
following discussions with Welsh
Government concerning our respective
roles
Page: 28 of 47
Public Health Wales
9.3
Develop a stakeholder
engagement plan to engage
with the diversity of
stakeholders in aligning
system-wide priorities with
the required support
9.4
Undertake a review of the
current capacity and
capability in NHS Wales to
inform decision-making for
investment, disinvestment
and the clinical and cost
effectiveness of high activity
interventions and make
recommendations to address
any gaps
9.6
Offer a checklist for running a
successful workshop to
investigate prudent
healthcare in a clinical area
Quality and Delivery Framework
Performance Report – Q2 2014/15
Red
Red
Amber
This is currently under consideration
following discussions with Welsh
Government concerning our respective
roles
This is currently under consideration
following discussions with Welsh
Government concerning our respective
roles
Delayed as awaiting guidance on role of
1000 Lives Improvement in taking
Develop and support an approach for a measurement framework for NHS
Wales, that connects measurement (and effort) at all levels to identify
waste and opportunities to improve care
9.20
Support the delivery of
prudent healthcare through a
half day workshop for chief
executives
11
Strengthen the public health impact of primary care
11.1
Support the development of a
vision for the future structure
for the delivery of primary
care in Wales by hosting two
workshops to build on
existing work, disseminate
evidence and good practice,
obtain stakeholder views and
support implementation
Amber
Amber
Delayed due to realignment of work but
rescheduled to present at CEOs meeting
at the end of October.
Primary Care models document produced
and submitted to WG. 1st of two
workshops have now been delivered.
Implement the Public Health Primary Care Network to strengthen the
public health impact of primary care
11.5
Update the content of the
Primary Care Network
website to signpost relevant
public health resources and
support to primary care
Amber
Will be completed by next quarter –
National Lead for Primary Care Network
will do when returns from India
Support the new GP Cluster Network development domain of the GMS
Contract for 2014/15
11.11
Produce indicators and a data
set for GP cluster network
performance
Date: 10/11/14
Amber
Version: 1
Agree at Primary Care Network held on
8th October 2014
Page: 29 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Engage with opportunities for quality improvement and public health
impact in the GMS Contract 2014/15
11.50
Develop electronic format of
collecting PDP and GP cluster
level information
11.51
Produce appropriate
indicators and data sets that
will support GP cluster
performance
Amber
On hold – need decision if NWIS will
produce this
Amber
Discussion at Primary Care Network
meeting on 8th October 2014
Provide quality improvement training on techniques such as audit and risk
in primary care
11.56
Offer quality improvement
training to prison health care
staff
12
Improve healthcare quality by providing professional leadership
12.41
Develop partnership between
All Wales Therapeutics and
Toxicology Centre, Public
Health Wales and health
boards to support the
development of antimicrobial
usage and resistance
surveillance systems
12.42
Provide guidance on policies,
strategies and initiatives to
influence prescriber and
patient/public behaviour in
conjunction with key
stakeholders and partners
Date: 10/11/14
Amber
Amber
Amber
Version: 1
Will be completed during quarter
Intention to progress this work via a
secondment by a member of PPHT to
AWTTC however the member of staff
involved is currently off sick
As 12.41
Page: 30 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Health intelligence
27
All actions to date delivered.
Policy, research and development
5
All actions to date delivered.
Date: 10/11/14
Version: 1
Page: 31 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Microbiology
3
6
Ref #
Action
Status
Notes
21
Improve access to modern infection diagnostics and management, through
the establishment of an all Wales managed microbiology service network
and service redesign
Developing the organisation
21.3
Develop an integrated
communications and ongoing
engagement strategy
Amber
Recent appointment of OD support
helping to address the matter
21.6
Identify core skills and
competencies for managers
and leaders
Amber
Part of the workforce planning
programme expected to complete by the
end of Quarter 3
Amber
Dialogue continues. Health Boards are
seeing an increase in activity levels yet
want to realise costs savings. Currently
we working on various demand
management initiates in support of their
cost overruns as a condition of signing.
Service development
21.10
Agree revised service level
agreements for diagnostic
microbiology services,
infection control and
specialist and reference
laboratories for 2015. These
will more accurately reflects
the requirements of health
boards and the offer from
Public Health Wales
Date: 10/11/14
Version: 1
Page: 32 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Screening
4
35
Ref #
Action
Status
Notes
23
Develop our screening programmes so they meet performance standards
Timeliness of service – cervical screening wait for results and laboratory
turnaround
23.33
Implement a standardised
‘lean’ pathway across each
key area, with potential
changes to cervical screening
policies to facilitate the
required reconfiguration
23.37
Implement first class post for
all results letters
23.39
Revise cervical screening
policies to support the
implementation of the
reconfigured ‘lean’ pathway
for laboratories
23.43
Reconfigure administration
functions to ensure
consistency in support
provided to laboratories,
thereby developing the
infrastructure to support a
reduction in result turnaround
times
Date: 10/11/14
Amber
Amber
Amber
Amber
Version: 1
Lean pathway agreed for labs, CSAD.
Key principles to be developed for smear
takers. SOPPs to go to October QM group
Data collated. Business case to go to
Cervical Modernisation Project Team 3rd
November 2014
Test of Cure SOPPs prioritised for
September. Timeliness SOPPs to go to
October Quality manual group.
Funding required to support additional
admin hours in Swansea CSAD. Business
case submitted against Trust
development fund- RF informed 30 Sept
that this bid has been unsuccessful.
Page: 33 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Health Protection
14
28
Ref #
Action
Status
Notes
26
Establish our strategic leadership of healthcare associated infections
(HCAIs) and antimicrobial use, with an appropriate balance of effort
directed at infections in the community and hospital settings (jointly with
microbiology)
Advice and support
26.1
Undertake series of meetings
(between September and
October) to discuss health
board action plans aimed at
reducing HCAIs and agree
bespoke support to be
provided through
development of joint action
plans
26.2
Deliver bespoke support,
including the analysis of data,
identified through discussions
with health boards
Amber
Amber
Dates for visits organised for most
healthcare organisations for Oct to Dec.
Some still outstanding
Visits not yet undertaken
Intelligence to inform action
26.9
Regularly review health board
surveillance data and notify
organisations of any unusual
activity through an agreed
alert system (further detailed
on the alert system is
provided within ‘Working in
Partnership to Reduce
Avoidable Infections’)
Date: 10/11/14
Amber
Version: 1
For HCAI surveillance, because of other
commitments within the operational
plan, work cannot start on an automated
system until Q3. A monthly manual
review of C. difficile and Staph
bacteraemia data is taking place in the
interim. For antimicrobial resistance
surveillance, discussions for a way
forward are in progress.
Page: 34 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Implement recommendations made within the HCAI Surveillance Review
undertaken in 2012/13
26.14
Move from continuous
surveillance of central venous
catheter infections to spot
checks
26.15
Investigate alternative
definitions for Ventilator
Associated Pneumonia (VAP)
26.20
Undertake studies into MSSA
bacteraemia, including a
review of source of MSSA
bacteraemia and comparison
of risk factors for MRSA and
MSSA bacteraemia in SAIL
Amber
Continuous surveillance has ceased.
Methodology for spot checks to be
decided (through critical care steering
group).
Amber
Investigation taken place. VAP Task and
Finish Group to decide on way forward.
Amber
Technical difficulties with final export
from HBs currently being worked on.
Education and training
26.22
Hold a stakeholder
engagement event to review
the contribution of Public
Health Wales’ health
protection teams and
stakeholders in community
based HCIA prevention and
control
26.24
Share best practice and
highlight essential principles
for effective Root Cause
Analysis (RCA) for HCAI in
conjunction with senior
infection control nurses
29
Design, develop and implement a plan for reducing liver disease,
addressing alcohol abuse, obesity, and blood-borne viruses
29.2
Review comments and submit
revised plan for approval
29.3
Support the establishment of
on all Wales Liver Disease
Implementation Group to
oversee the implementation
of actions stemming from the
delivery plan
29.4
Collate evidence based in
relation to NICE Guidance
and other guidance around
the primary prevention of
obesity, alcohol misuse and
blood borne viral hepatitis
Date: 10/11/14
Amber
Amber
Amber
Amber
Amber
Version: 1
Event postponed from original date to
October /November 2014, supported by
1000 lives event team;
Lack of cohesion between HBs and WG in
degree of standardisation.
The plan has yet to be issued for
consultation, it has been indicated that it
may be issued in October-It is not clear
that we will necessarily be required to do
this
The plan has yet to be issued for
consultation, it has been indicated that it
may be issued in October. The
implementation group has yet to be
established
There was a delay in appointing the staff
member to back fill to enable this work
to progress. This appointment has now
been made
Page: 35 of 47
Public Health Wales
29.9
Work with health boards and
the all Wales Liver Disease
Implementation Group to
identify individuals with
hepatitis B or C infection and
offer them specialist
assessment and treatment
31
Sexual health
Quality and Delivery Framework
Performance Report – Q2 2014/15
Amber
The implementation group has yet to be
established

31.3
Develop and implement plans
for the delivery of LARC
within substance misuse
services through providing
support to services within
health boards in the
identification of staff for
formal faculty theory and
practice based training
Amber

Provision of training – discussions are
ongoing with the Faculty of
Reproductive & Sexual Health
regarding the most effective way to
provide ‘places’ for the theoretical
element of the letters of competence
so that relevant staff can easily take
the opportunity to achieve this
qualification.
Contacts in HBs are making staff
aware of this opportunity and are
providing names of those who wish
to train.
Some HBs already have staff in place
who are trained to provide LARC and
are, therefore, being supported to do
this.
31.4
Work with services to develop
data collection methods,
including through the Harm
Reduction Database or via
paper based forms, to
support the delivery of LARC
within substance misuse
services
Date: 10/11/14
Amber
Version: 1
Ongoing
Page: 36 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Safeguarding
1
1
Ref #
Action
Status
Notes
33
Further develop arrangements for safeguarding children
Undertake an ongoing leadership role for NHS engagement with adoption
33.16
Complete work with All Wales
Looked After Children (LAC)
nurses group and British
Association for Adoption and
Fostering Welsh Medical
Group regarding mapping
exercise and needs of LAC
Date: 10/11/14
Amber
Version: 1
33.15 completed ahead of time and
33.16 due for completion in Q4
Page: 37 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Enablers
Relationships and interdependancies
2
2
Ref #
Action
34
Develop and implement revised accountability arrangements
34.1
Agree and implement a new
accountability agreement with
the Welsh Government defining
our specific accountabilities for
taking action and achieving
outcomes and our role within
cross-organisation performance
management
Amber
34.4
Agree, where appropriate,
service level agreements
covering the provision of
specific services by Public
Health Wales and health boards
to the other party
Amber
Date: 10/11/14
Status
Version: 1
Notes
Given that Public Health Wales is fully
integrated in the NHS Planning and
Performance framework, discussions
with Welsh Government have
concluded that there is probably little
value in finalising the agreement as
originally planned. Discussions are
ongoing as to whether this action
should be removed.
Page: 38 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Worforce and organisational development
12
16
Ref #
Action
Status
Notes
Align our workforce to priorities and develop and maintain sufficient skills
and knowledge
35
Develop and equip staff to work effectively and in new ways, through
investing in skills across the workforce
Develop and equip staff to work effectively and in new ways, through
developing leadership and management skills
Workforce planning
35.15
For each division, identify the
succession needs and put in
place a plan to replace
expected retirees over the next
3 to 5 years
35.16
For each division, identify hard
to fill posts and gather
intelligence on recruitment
markets and secure alternative
sources of recruits
35.18
Embed organisation design and
workforce planning capability
within the service redesign
programmes, to ensure that
these aspects are fully taken
into account in delivering the
change programmes and that
the future workforce is
sustainable
Date: 10/11/14
Amber
Amber
Amber
Version: 1
Majority of work completed, but some
work delayed due to staff sickness
Divisional baseline information is in
process but delayed due to staff
sickness
Interim support secured for
Microbiology and Stop Smoking Wales
for a limited period only.
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Electronic staff record
35.20
Establish the extent to which
ESR has been fully
implemented and
Amber
develop and implement a
project plan to fill any gaps
Work on the project has now began
following the appointment to a new
post of ESR Manager.
Employee relations
35.24
Work with the AfC trade unions
to develop principles to
underpin ways of working
together and be clear about the
deal between the parties
Amber
No further development following the
workshop in March due to lack of HR
and TU availability.
Performance management and appraisals
35.31
Ensure all managers are clear
about importance of completing
staff appraisals and of the
target set
Amber
Achieved increase from 53% to 77%
but further work to be done.
Executive Report and upward
feedback survey actions rolled over to
Q3
Leadership and management development
35.49
Develop and implement
selection techniques to assess
criteria
35.52
Procure development solutions
35.56
Develop a series of master
classes on key management
and leadership topics such as:
large scale change, powerful
conversations, creating
engagement and wellbeing,
communications and
storytelling
Amber
Amber
Amber
We have implemented assessment
centres using a range of techniques.
We need to formalise our recruitment
processes and increase HR capacity to
deliver.
The OJEU process has taken a little
longer than predicted. Contracts will
be in place by end of October 2014.
Master class for Powerful
Conversations and Effective
Relationships have taken place.
Tender process begun for full range of
topics including management and
leadership envisaged for October
2014 (linked to 35.52)
Supporting organisational change projects
35.57
Provide sound organisational
design advice, ensuring fair
treatment of staff and
supporting managers in
delivering change. These
projects and programmes
include:
35.57d
Cervical screening
modernisation
Date: 10/11/14
Amber
Amber
Version: 1
While some additional OD resource is
in place it is stretched very thin and
programmes not yet embracing full
range of OD support.
Due to the stage the programme is
at.
Page: 40 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Values and “the deal”
35.60
Provide advice to the Executive
Team on developing the
narrative to communicate the
strategy
Amber
This will be completed in Q3 as the
narrative is aligned with planning
process for the next IMPT.
Quality and Governance
1
2
2
Ref #
Action
36
Put in place a comprehensive governance framework that addresses the
issues raised by the Francis Report
36.3
Ensure that we comply with the
Welsh Government aim of
reaching a target of 25% of the
NHS workforce being trained in
Improving Quality Together
Red
36.4
Work with AcademiWales to
source a board development
programme for the whole board
and individual board members
Amber
Meeting with Academi Wales
postponed. Meeting urgently being
arranged.
36.8
Ensure that the key annual
governance documents read as
a suite of documents which are
interdependent, joined up and
are citizen and staff focused
Amber
All key documents in place. Review
will now take place in Q3.
Date: 10/11/14
Status
Version: 1
Notes
Latest figure is currently 9271
individuals have completed IQT
training in NHS Wales.
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Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Sustainable Development
2
All actions to date delivered.
Informatics
5
12
Ref #
Action
Status
Notes
39
Develop and equip staff to work effectively and in new ways, through
developing and providing informatics tools and services
Facilitate rapid, interactive data analysis and presentation through the
adoption of a Business Intelligence System (BIS)
39.7
Public Health Wales
Observatory Analytical Team to
engage in training and produce
outputs for early years
Date: 10/11/14
Amber
Version: 1
The Observatory has access to
Tableau but insufficient time to use it
to produce outputs due to problems
with the data set. Traditional methods
are being used to generate the
reports.
Page: 42 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Facilitate collaboration through more effective use of Groupware
39.8
Review the use of Groupware
solutions within Public Health
Wales and make
recommendations for future
use, informed by existing
experience with Notes and
SharePoint
40
Support modern public health service delivery and the delivery of targeted,
interactive digital services by securing the necessary informatics systems
Amber
Delays in funding for upgrading to
SharePoint 2013 and the consultancy
report which envisages greater
changes than anticipated. Will require
additional time to program changes.
Implement and take advantage of TrakCare, the new Laboratory
Information Management System (LIMS)
40.5
Subject to the system and its
implementation being fit for
purpose, deploy TrakCare in
our cervical cytology
laboratories
Amber
Delays imposed by NWIS and/or
Intersystems delivering outcomes ontime. Re-planning required, possibly
to go live Q4.
Develop and implement systems to support the delivery of microbiology
and health protection services
40.9
Scope the bioinformatics
requirements for next
generation genomic sequencing
Amber
Work has slowed due to absence of a
set of user requirements
Develop and implement systems to support the delivery of screening
programmes
40.15
Implement the Newborn
Bloodspot Screening Wales
System (NBSWS), including
links to Child Health System
and facility to generate
parental letters
Amber
Delays in progressing the specification
of new bloodspot processes mapped
to LIMS means that other modules
will require re-planning
Working Environment
1
Date: 10/11/14
Version: 1
Page: 43 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
All actions to date delivered.
Service User Experience
2
Ref #
Action
42
Put in place a comprehensive service user experience framework
42.1
Appoint a service user
experience coordinator to
provide additional leadership
and support on this agenda
(1WTE band 7)
42.7
Develop and implement a
performance framework, which
will be regularly reviewed by
the Quality and Safety
Committee and Board, and
share service user/staff stories
in these forum
Date: 10/11/14
Status
Notes
Amber
Appointment of Lead Nurse delayed
due to length of time taken to band
post. Now banded and job currently
being advertised.
Amber
Draft templates piloted by
programmes to enable triangulation
of data. Service User Lead not yet in
post. Service user/staff stories shared
at Q&S Committee/Board
Version: 1
Page: 44 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Communications and stakeholder engagement
5
Ref #
Action
43
Review, develop and implement our Communications Strategy
43.3
Agree a way forward for the
review of the internal
communications strategy with
the Executive Team
43.4
Conduct interviews with key
members of staff to gather
qualitative research
43.5
Conduct a survey with staff to
gather views on the different
ways of communication
43.6
Conduct a review of key
internal communications
outputs (usage, coverage,
inclusion of information etc)
including: Staff e-Bulletin;
intranet site; staff forum; open
blog
43.9
Develop public affairs strategy
and action plan
Date: 10/11/14
Status
Notes
Amber
Actions on reforming internal
communications have been delayed
due to capacity issues. The work has
been rescheduled to take place over
Q3 and Q4
Amber
Actions on reforming internal
communications have been delayed
due to capacity issues. The work has
been rescheduled to take place over
Q3 and Q4
Amber
Actions on reforming internal
communications have been delayed
due to capacity issues. The work has
been rescheduled to take place over
Q3 and Q4
Amber
Actions on reforming internal
communications have been delayed
due to capacity issues. The work has
been rescheduled to take place over
Q3 and Q4
Amber
We have prepared a scoping report. A
new strategy will be implemented
along with the introduction of a
stakeholder management system, to
be procured in Q3
Version: 1
Page: 45 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
Planning and Performance
5
11
Ref #
Action
44
Implement a revised planning framework
44.6
Establish a public health
planning group, which will
include representatives from
each health board area to
support greater alignment
between health board and
Public Health Wales’ Integrated
Medium Term Plans
44.7
Complete 2014/15 actions from
staff, stakeholder and public
engagement plan for future
planning
44.8
Scope potential to hold
planning master class to
support development of skills
for key staff involved within
planning process
45
Develop and implement revised performance reporting
45.1
Update Public Health Wales’
Quality and Delivery
Framework in collaboration
with the Welsh Government,
including measures of service
user experience
Date: 10/11/14
Status
Amber
Amber
Amber
Amber
Version: 1
Notes
Working groups, including health
board representatives, to take
forward development of joint priorities
work.
On hold due to resource issues. To be
taken forward in future quarters.
Need and viability to be determined.
Initial discussion held with Welsh
Government, work likely to be
completed in first part of Q3
Page: 46 of 47
Public Health Wales
Quality and Delivery Framework
Performance Report – Q2 2014/15
46
Review and update our business continuity arrangements
46.3
Audit and review our current
business continuity
arrangements within each
division to identify areas of
best practice and any potential
gaps
Date: 10/11/14
Amber
Version: 1
Initial audit undertaken but work
delayed due to prioritisation of NATO
response.
Page: 47 of 47