Health Informatics Service. Accreditation. Standards

Transcription

1 Health Informatics Service Accreditation Standards Version 5.4 September 2012

2 Contents 1 INTRODUCTION Overview Aim of this Document HISA Standards Owner Rationale and Benefits of Service Standards and Accreditation Review and Approval of Certification Processes Allocation of and Score to each Standard Evidence Intellectual Property Right Definitions... 5 SECTION 1 SERVICE DESCRIPTION... 6 SECTION 2: GOVERNANCE AND PLANNING... 9 SECTION 3 CORPORATE AND COMMERCIAL SECTION 4 - WORKFORCE SECTION 5 SERVICE DELIVERY SECTION 6 - ASSURANCE... 57

3 1 INTRODUCTION 1.1 Overview The Health Informatics Services Accreditation (HISA) s have been developed by DH Informatics Directorate (DHID) with the support of Chief Information Officers, directors of informatics services, the NHS Health Informatics Benchmarking Club (HiBC) and representatives of customer organisations. The foundation for the HISA s was the portfolio of s jointly developed by DHID and the HiBC for use by services to benchmark themselves against their peers. The HISA s have been piloted with a range of informatics services, supplemented with consultation with other subject matter experts. The HISA s are relevant to all types of informatics service and IM&T department, which typically fall into one of the following categories (note that within this document the term HIS refers to all types of informatics service as listed below and an informatics delivery function is also referred to as the Service ): In-house Service typically provided to a single organisation. Managed Service, where one organisation provides services to another. Shared Service, hosted by an NHS organisation, providing services to a number of others. Outsourced Service from within the NHS or from the private sector. The HISA s are designed for and certification of providers of informatics services within the framework of an accreditation scheme. Certification is the confirmation of specific characteristics of an object, person, or organisation usually with some form of external review or, and usually against a pre-defined set of s. Accreditation is an independent confirmation of the service s performance against s. The HiBC will continue to maintain and develop its portfolio of benchmarking s, most of which will replicate the HISA s. 1.2 Aim of this Document The aim of this document is to list the HISA s. 1.3 HISA Standards Owner DH Informatics Directorate currently owns the HISA s. The intention is that ownership will move to an appropriate agency. 1.4 Rationale and Benefits of Service Standards and Accreditation The NHS is moving towards increased plurality in service provision, including the provision of informatics services. Commissioners advise they often lack access to objective measures of informatics services capabilities and performance. Setting service s, supported by both parties, will aid the service commissioning process. The vision for the accreditation of health informatics services is as follows: For all providers of informatics services to the NHS to be accredited using HIS accreditation s, in order to support patient care and provide value for money services. The expected benefits of HIS accreditation include the following:

4 Support local decision making in respect of commissioning and delivering informatics services by increased availability and transparency of relevant information. Provide assurance to local commissioners that minimum s are being met. Support continuous improvement, focussing informatics services on their key performance areas. Provide public acknowledgement of an informatics service s performance. 1.5 Review and Approval of Certification Processes The HISA s are approved by the HISA Standards Board, which conducts an annual review with reference to subject matter experts. 1.6 Allocation of and Score to each Standard The HISA s are divided into 6 sections as shown below: Section 1: Service Description Section 2: Governance and Planning Provides contextual information about the service and is not assessed Section 3: Corporate and commercial Section 4: Workforce Section 5: Service Delivery Section 6: Assurance The Service Delivery section has several specialist areas Within each section is a range of s and each is allocated a weighting of 1, 2 or 3. Several of the s are designated as Mandatory. These are the key indicators of a service s performance and are therefore weighted as 3. Each has a number of statements that indicate an informatics service s compliance with that. The number of statements is between 3 and 5, and each carries a score (e.g.,,, and, where 5 is most mature, and 1 is least performing or needing most development). Some s do not warrant a 5 or 4 score on the maturity, and so a response of A sometimes results in a score of 3 rather than 5. Where the s are used within an accreditation scheme, the following scoring model is applied and moderated: an informatics must comply with the conditions below in order to achieve accreditation: To gain a pass in any one section or specialist area the average score, taking weighting into account, has to be 3 or above. All mandatory s must score 3 or above 1.7 Evidence The guidance for each provides examples of documents that an informatics service might use to evidence its compliance with that. In addition, a service might cite compliance with other s or schemes (such as BSI British Standards, ISO s,

5 SOCITM ICT best practice, NHS Infrastructure Maturity Model (NIMM) and ITIL best practice for IT service management). 1.8 Intellectual Property Right DH is the owner or the licensee of all intellectual property rights relating to the HISA s and any accreditation scheme based on the s. 1.9 Definitions Term Informatics Service Types of Informatics/ IM&T Service: In-house Service Managed service Shared Service Out-sourced Service Host Organisation Definition A generic term used to describe the agencies that deliver informatics services to a customer. Within this document an informatics delivery function is also referred to as the Service. Typically provide services to a single organisation. Where one organisation provides services to another. Hosted by an NHS organisation, providing services to a number of others. From within the NHS or from the private sector. The agency that provides the infrastructure and governance to support an informatics service. Customer Organisation Service User Accreditation Certification Benchmarking The agency that negotiates with the informatics service and purchases its services, and has the ability to choose between different suppliers. Those who use the services purchased by the customer from the informatics service. Accreditation is the formal recognition by an accreditation authority to the technical and organisational competence of a conformity body to carry out a specific service in accordance to the s and technical regulations as described in their scope of accreditation. It is an independent confirmation of a service s performance against s. The confirmation of specific characteristics of an object, person, or organisation usually with some form of external review or and usually against a pre-defined set of s. A process of comparing business processes and performance metrics to industry bests and/or best practices and/or best practices from other industries.

6 SECTION 1 SERVICE DESCRIPTION Section 1 provides contextual information about the informatics service and is not assessed. Ref Information Requirements 1.1 Full name of the informatics service and, if relevant, its host organisation 1.2 Name and contact details of the Director or Head of Service for the informatics service 1.3 Name and contact details of the point of contact within the informatics service for accreditation 1.4 Indicate the categories of services provided: 1. ICT 6. Information Management 11. Business Intelligence (BI) 2. Information Governance 7. Telecommunications 12. Other (please describe) 3. Medical records 8. Clinical Coding 4. Library 9. Training 5. Knowledge Management 10. Data Management & Integration Centre (DMIC) Service Catalogue, Service Schedule. 1.5 Total income passing through the Informatics service account: Total income is an indicator of service size and should recognise the annual income value, whether this is a series of income streams from several customers or an allocated budget for an internally-provided service. The total number should relate to annual turnover; i.e. recurrent revenue. Capital should not be included. A - Less than 499,999 B - 500, ,999 C - 1, ,999,999 D - 5,000,000 9,999,999 E - More than 10,000,000 balance sheet, budget/finance report. In addition, where relevant, state the size of the host organisation s budget to the nearest m, to indicate the proportion allocated to the Informatics service.

7 Ref Information Requirements 1.6 Number of customer organisations the Informatics service supports. A customer is an agency that negotiates with the informatics service and purchases its services, and may choose between different suppliers. This refers to separate organisations rather than, e.g. different divisions or departments in a hospital trust. A - One B - 2 C D E - More than 10 contracts, SLAs, organisational charts. 1.7 Total number of sites supported by the Informatics service A site is a building or set of buildings with a name that clearly separates them from other buildings or sets of buildings with a name. For example, a foundation Trust running South Town University Hospital and North Town Hospital would count as two sites. A Pathology building and a Physiotherapy building on the same hospital site would count as one. Count a GP practice as one site. Number of discrete physical sites covered: A - Fewer than 29 B C D E - More than 300 contracts, SLAs, organisational charts. 1.8 Total number of service users: Those who use the services purchased by the customer from the informatics service. Number of service users in customer organisations with an account, including service users supported by an in-house service. A - Fewer than 999 B C D - 10,000-19,999 E - More than 20,000 Service Desk report showing number of accounts.

8 Ref Information Requirements 1.9 Total number of staff working in the Informatics Service. a. Total number of staff working for the Informatics Service. A - Fewer than 29 B C D E - More than 300 b. Please indicate the areas in which the staff work (e.g., ICT, information management, training etc.) c. If relevant, please indicate the approximate split between Data Management & Integration Centre and Business Intelligence report showing number of whole-time equivalent posts or head count, structure chart.

9 SECTION 2: GOVERNANCE AND PLANNING The Governance and Planning section considers the processes and checks associated with a Service that has good internal controls and effective governance and methodology for interacting with commissioners and customers. Ref Standard Guidance and examples of against the 2.1 The Service has strong and effective strategic function and influence with Board engagement and approval. NHS Board could be a Trust or Commissioning Support Unit (CSU) Board, or equivalent body, at organisational. For a managed or shared service, approval from both the management board and board approval from customer organisations. an Information Strategy or equivalent, strategic frameworks and processes with Board- agreement and approval, original approaches that transform ways of working at a strategic, clear integration with customer business process and national initiatives (e.g. QIPP), a CSU business plan and strategy that identifies the importance of a data management information centre to business intelligence and overall CSU development. is highlighted in bold font A The Service s influence extends beyond the provision of informatics services to influence the management and development of the customer s wider business, with clear evidence of innovative and transformative activity. There is clear evidence of innovation and of action taken in response to the informatics service s influence on host organisation s strategies. B The Service s influence extends beyond the provision of informatics services to influence the management and development of the customer s business. Strategies are integrated within a host organisation s strategy. C - The Service has Board influence and engagement in respect of informatics services. Strategy is aligned with a host organisation s strategies. D - When required, and in response to customer requirement, the Service has the opportunity to influence the Board. There is evidence that the informatics service s strategy is developing its alignment with a host organisation s strategies E - The Service never or rarely has the opportunity to influence the Board. There is no clear alignment with the host organisation s strategies.

10 against the 2.2 Business planning and business case processes and guidance are followed within a clear governance framework incorporating informatics processes, and Board- approvals are secured where required. NHS Board could be a Trust or CSU Board, or equivalent body at organisational. For a managed or shared service, this means approval from both the management board and board- approval from customer organisations. Board approved business plan(s), minutes of steering group or Board subcommittee meetings, internal audit report showing compliance with local guidance, Standing Financial Instructions. is highlighted in bold font A - Systematic business processes and business case s are routinely and consistently applied in all cases across all customers and for all service elements, with Board- approval. B - Systematic business processes and business case s are routinely applied for key service areas, and/or as requested by customers, and have Board- approval (not necessarily separate approval for each individual case). C - Business processes and business case s are occasionally applied for key service areas, as requested by customers, but do not always have Board- approval and/or are unsystematically applied. D Business processes and business case s are occasionally or rarely applied, or there is unsystematic application of business processes and business case s. A=4 B=3 C=2 D=1 2.3 The Service works with customers to identify key performance indicators. Formal processes and measures are in place, which identify the key performance objectives of the service in relation to customer need and requirement. sets of KPIs and evidence that these are shared on a regular basis with customers, Supporting Informed NHS Customers for IT A Formal measures used with all customers (in-house and external where a service is provided), except where the customers have formally agreed that they do not want external measures. Clear governance is in place to support the process. B - Measures and processes exist at informal or formal based on customer requirement, with some evidence of appropriate A=4 B=3 C=2 D=1

11 against the stry/support) is highlighted in bold font governance. C- Some measures, whether formal or informal, are in use with some customers some of the time but are not formally adopted. Limited evidence of governance to support the process. D - No measures in use. 2.4 Where applicable, action plans are in place to address where key performance indicators are not being met. set of KPIs with documentation demonstrating action to address non delivery, application where relevant of penalty and reward clauses. A - A formal action plan is in place (inhouse and external where a service is provided) for all customers, that is pro-active in nature and anticipates future events. Clear governance is in place to support the process. B - A formal action plan is in place with all customers, with some evidence of appropriate governance. C - A informal plan exists with all customers/or a formal plan is in place with some customers. Limited evidence of governance to support the process. D - No plans or governance in place. A=4 B=3 C=2 D=1 No The Service is closely involved in a Benefits Management methodology for programmes and projects. Benefits Management includes benefits identification, benefits planning, benefits realisation, benefits tracking and reporting Of key importance are: Benefits have been identified and planned with appropriate stakeholders, who can take ownership and responsibility of the benefits and continue to deliver them after the A - There is a recognised and consistently applied benefits management methodology for all projects and programmes where relevant, with demonstrable evidence of success. Clear governance is in place. The methodology is regularly reviewed and cited regionally or nationally as best practice. B - There is a recognised and consistently applied benefits management methodology for A=4 B=3 C=2 D=1

12 against the project/programme is complete (i.e. customers, rather than the project / programme team). Each benefit has an identified owner who has the authority, responsibility and access to be able to deliver the benefit (NOT the Chief Exec, but the person at the front line who can make this happen). Benefits are on the agenda of the project/ programme management board. is highlighted in bold font most projects and programmes where relevant and at the customer s request, with demonstrable evidence of success. Some evidence of appropriate governance. C The use of a benefits management methodology is ad hoc and/or the methodology is limited in depth and breadth. Limited evidence of governance to support the process. D No benefits management methodology is in place. documented methodology showing application, costings, patient benefits, clear links between project initiation documents, outcomes and benefits, meeting. 2.6 The Service has robust financial management systems in place. Board reports, budget reports with s of designated authority and compliance with standing financial instructions, meetings and audit reports. A There is a designated finance resource at finance manager (who may be a member of the senior team), who is involved in service delivery, business planning and budget setting with at least four s of finance reporting, an independently audited set of accounts and a robust reporting system to the accounting organisation. B A designated finance resource at finance assistant is involved in service delivery and budget setting with at least four s of reporting, independently audited set of accounts and a robust reporting system to the A=4 B=3 C=2 D=1

13 against the is highlighted in bold font accounting organisation. C There is no designated finance resource. There are centralised budget reports which are only issued to the most senior managers and/or limited evidence of independent audit. D - No clear system of operation is in place. 2.7 Formal P3M (Project, Programme and Portfolio Management) methodologies are recognised and used. The focus here is project management within the informatics service (Section 5 covers the provision of project management to its customers). board minutes and TORs, reporting structures, benefits documentation, risk documentation, Gateway reports, and application of PRINCE2, Managing Successful Programmes, Agile or other methodology. also A A recognised P3M methodology is applied to all relevant projects and programmes that the Service manages, with demonstrable evidence of success. The methodology is regularly reviewed and cited regionally or nationally as best practice. B A recognised P3M methodology is applied to all relevant projects and programmes that are managed by the Service, with demonstrable evidence of success. C A recognised P3M methodology is applied to some relevant projects and programmes managed by the Service and/or is inconsistent in its application. D No P3M methodology is applied. A=4 B=3 C=2 D=1 2.8 There is regular dialogue between the director/head of the Service and the chief executives, or nominated executive holding the informatics portfolio, of Dialogue could be formal or informal and applies equally to internal providers as well as those providers who support one or more organisations. A There are regular, planned meetings with all customers CEOs. B - Meetings with CEOs or nominated executives take place when required or via management/governance structures. A=4 B=3 C=2 D=1

14 against the customer organisation(s). evidence of regular meetings, correspondence. is highlighted in bold font D - No formal processes at all; contact is mostly informal and on an opportunity basis. D - No regular dialogue. 2.9 The director/head of the Service has good Board- engagement and representation. NHS Board could be a Trust or CSU Board or equivalent body at organisational. For a managed or shared service, approval from both the management board and board approval from customer organisations. evidence of regular meetings, correspondence. A - The director/head of the Service is a member of their host organisation s Board and is a representative of the Service when attending meetings of customer organisations. Attendance is not dependent on informatics matters being discussed. B - The director/head of the Service is a member of their host organisation s Board but is an infrequent representative of the service on customer organisations Boards. C - The director/head of the Service attends its host organisation s Board when informatics matters are discussed. D The director/head of the Service provides routine updates to the host and customer organisations Board via papers or through members of the Boards. E Limited or no evidence of informatics being routinely covered at Board.

15 SECTION 3 CORPORATE AND COMMERCIAL The Corporate and Commercial section concentrates on the relationship between the Service and those who commission and use the service. The emphasis is on service agreements and key performance indicators, as well as other performance management methods. The section also considers asset management and carbon reduction, and seeks assurance that the Service has appropriate systems in place in order to demonstrate value for money. Ref Standard Guidance and examples of against the 3.1 The Service has a contract(s) or Service Level Agreement(s) (SLA) with those who use its services. SLA/contract. is highlighted in bold font A Contracts/SLAs are negotiated and agreed on a regular basis with customer (s), with associated performance indicators. B A contract or SLA is not formally negotiated with the customer(s) but is in place, with associated performance indicators, and working towards having formal contracts or SLAs in place. C- No contracts or SLAs are in place. A=3 B=2 C=1 3.2 The Service regularly reviews contractual/core purpose performance so that the service remains effective and efficient, delivering against objectives, with appropriate focus on the following elements: risk investment delivery accountability responsibility Mechanisms for correcting and redressing under-performance should be in place. documentation demonstrating review and follow-up activity. A - Processes and procedures are in place to deliver against objectives in respect of all of the listed elements with all customers, giving real-time assurance on contracts and their current and on-going value across all organisations and service. B - Processes and procedures are in place to deliver against objectives in respect of the majority of the listed elements with all customers or all elements with some customers. C - Working towards implementing of some or all of the listed elements, with some processes and procedures in place with a number of cases. D - None of the listed elements are in place. A=4 B=3 C=2 D=1 No 2

16 against the 3.3 An effective licence management system is in place and linked to operational systems. documented licence management system and clear link to operational systems, examples of application. is highlighted in bold font A An effective system is in place for all licences owned by the Service and for licences owned by customers as agreed with them. B - An effective system is in place although not linked to operational systems. C - A system is in place, which might be stand-alone, but is not utilised by all customers. D - Out of date or no formal system is in place. A=4 B=3 C=2 D=1 3.4 The Service supports re-use and disposal procedures and criteria for its own services and those of customers; these are integrated with asset management systems. Re-use means re-assigning equipment to another user or selling it where, for example, a member of staff leaves, a department closes or the equipment is superseded by a newer version. documented processes and their application. Evidence of new, original thinking and working, with continual improvements being made. A - Comprehensive and proactive reuse and disposal procedures are in place and integrated with asset management systems, with evidence of innovation and or original thinking, and in concert with customers. B - Re-use and disposal procedures are in place and integrated with asset management systems and in conjunction with customers. C - Re-use and disposal procedures are in place and routinely integrated with asset management systems as and when required. D Re-use and disposal procedures are not in place. A=4 B=3 C=2 D=1 No The Service has, or recognises, a carbon reduction programme or some other form of green IT strategy. The focus here is green activity within the informatics service (Section 5 covers the delivery of a green agenda to its customers). carbon reduction or green IT strategy, A - A leading edge strategy for the informatics service, approved at Board, is in place and associated with an effective delivery programme. Nationally recognised, innovative practice and registered with the Carbon Trust or other No 1

17 against the examples of activity if not necessarily covered by one overarching strategy, use of, e.g. SOCITM KPIs. is highlighted in bold font relevant body. B - A strategy is in place within the informatics service, approved at Board, and in use, covering all equipment and is integral with the full service offering, and is included in all planning processes/documents. C - A strategy is in place and applied to some components and/or equipment. D Elements of green IT practice and carbon reduction programme are in place, although not captured in an over-arching strategy. E Not in place, or working towards a green strategy for the informatics service. 3.6 Cost reductions and/or efficiency plans are in place with associated implementation programme(s). Plans and programmes are live and associated with year-onyear planning processes. documented plans, reports on implementation outputs and benefits (e.g. cost savings on energy use). A All of these in place with all customers. B Some plans with more than one-year lifetime in place with some customers. C Some plans have been developed, without formal structure or governance to them. D Developing plans but currently no clear evidence of implementation. A=4 B=3 C=2 D=1 3.7 A process is in place for measuring service line costs. participation in relevant workshops, data arising from use of a costing model, documented processes, and examples of where, by using a recognised model, data is shared with other informatics delivery agencies. A - A recognised model is applied, or a local model is used and validated against best practice, and used across all service lines. B - All service lines are included but the model is not validated against best practice. C- A process is applied to at least 50% of service lines. No 2

18 against the is highlighted in bold font D - Developing a process and/or model but currently no clear evidence of implementation. E- No process is in place and no plans to implement one.

19 SECTION 4 - WORKFORCE This section is considers workforce planning and development, recognising the need to have people who are appropriately trained and looks for evidence of training, records and plans that are associated with individuals rather than the Service as a whole. It also considers communication within the service and the positioning of the informatics service within a host organisation. Ref Standard Guidance and examples of against the 4.1 The Service manages its workforce planning in a systematic and proactive fashion. Effective workforce planning ensures a workforce of the right size, with the right skills, organised in the right way within an affordable budget, delivering services to provide the best possible care. This requires a planned approach to workforce planning. workforce plan, skills audit, documented areas of risk, change management projects. Use of a recognised approach; e.g. NHS Employers tools & resources ( Skills for Health Six Steps. or Centre for Workforce Intelligence ( Note that workforce planning for the informatics service could be part of a wider plan and related activity owned by the host organisation. is highlighted in bold font A - A Board-approved workforce plan is in place that is a pro-active and current, with processes to help the organisation manage changes in demand for workforce skills, capability and capacity. It identifies key areas of risk and proposes strategies to minimise risk and deal with change. It is systematically reviewed and is cited regionally or nationally as best practice. B - A Board-approved workforce plan is in place, with evidence of implementation within the informatics service, and which is systematically reviewed. C- A workforce plan is in place, approved by director/head of the informatics services, with evidence of implementation and systematic review. D There is no formal, approved workforce plan but there is evidence of workforce planning within the informatics service. E There is no workforce plan and limited or no evidence of workforce planning activity within the informatics service. No 2

20 against the 4.2 The director/head of the Service holds a senior position within the host organisation. structure chart, minutes of meetings. is highlighted in bold font A - Reports directly to the host organisation s Chief Executive Officer. B - Reports directly to an executive director who sits on the host organisation s most senior board. C - Reports directly to another director who does not sit on the host organisation s most senior board. D - Reports directly to another manager, who does not sit on the host organisation s most senior board. A=4 B=3 C=2 D=1 No There is an effective mechanism for regular review of responsibilities and prioritysetting for the Service. terms of reference, of meetings such as a customer board, development process and plans. A - A system is in place to regularly review responsibilities and priorities, with appropriate and effective connections to all customers and stakeholders,. B - A system is in place to review responsibilities and priorities, with appropriate and effective connections with some customers. C - A system to review responsibilities and priorities is in place but there is limited evidence of appropriate and effective connections with customers at senior. D A mechanism if it exists is ad hoc and informal in nature. A=4 B=3 C=2 D=1 No The Service has robust human resource (HR) systems in place which include the following elements: Recruitment & Selection Discipline & Grievance Induction & Orientation Current HR policies, processes and systems are in place to support all s of the workforce; i.e., those who manage staff and individual employees. These might not be owned by the informatics service but the service should have access to relevant expertise, policies and systems. A - The informatics service has regular, formalised access to HR expertise and regular dialogue with HR staff to inform decisions on managing the workforce. The service has access to extant HR policies and systems covering all key HR elements listed in the. The service works collaboratively on strategic and A=4 B=3 C=2 D=1 No 2

21 against the Developing new skills Workforce Planning Staff Consultation Performance appraisal Disbursement of wages, incentives and allowances Travel and related expenses application of HR policies and procedures by informatics service, of meetings with HR, sickness absence records and examples of where HR action has been taken by the information service with support/advice from HR such as discipline, grievance, re-grading, recruitment & selection. Informatics representation on groups reviewing and revising HR policy and systems. is highlighted in bold font operational HR issues (e.g. workforce planning and reconfiguration). Longterm planning with respect to HR is a clear feature of the Service s approach. B There is access to HR expertise, policies and systems on an as required basis, which covers all key elements listed in the. The emphasis is on taking a pro-active approach to HR activity. C- The informatics service has a reactive approach to HR. HR activity in the informatics service does not cover all elements listed in the but is limited to essential activity such as recruitment and sickness absence reporting, with little evidence of regular dialogue with HR in order to inform good practice. D- The service has no access to expert HR advice, policies or procedures. HR decisions are taken in house with no reference to evidenced good practice. 4.5 The director/head of the Service communicates with his or her team on a regular basis and there is regular communication between staff at all s. Includes open door policy, regular communications, regular team meetings, regular communication of the Service s priorities, extended meetings allowing team workers to see middle and senior managers in operation, leaders walking the department and operational sites. Should include two-way communication and allow issues and questions to flow up from front line A Regular communication across and between staff at all s in the Service, using a variety of communication means and mechanisms (often on a daily basis) and includes 2-way feedback processes. Evidence that indicates communication processes have contributed to increased productivity, efficiency, staff retention and morale. B Regular communication across A=4 B=3 C=2 D=1 No 2

22 against the staff too. from meetings, briefings, newsletters, briefings, intranet, case studies, staff survey feedback, evidence of action to respond to staff queries and concerns. is highlighted in bold font and between staff at all s in the Service, using a variety of communication means and mechanisms (invariably on a daily basis). No direct evidence of effect. C There is communication, although this may occur irregularly, or meetings are held only to discuss a specific issue. D Little or no evidence of communication between staff. 4.6 Staff within the Service possess appropriate and relevant qualifications, where these are available. Include only relevant training and qualifications; e.g. a degree in an appropriate discipline or other qualification as specified in a job/role person specification. Relevant means in relation to the role and position the staff member is filling. A % B - 60% - 90% C - 40% - 59% D 20% - 39% E less than 20% The denominator (d) is the number of informatics staff in all areas where qualifications are available. The numerator (n) is the number of staff with those qualifications. d divided by n X 100 = percentage of staff with appropriate and relevant qualifications. Examples of qualifications: Director/Head of Service: management or professional development qualification. Specialist head/manager: specialist qualification. Project/Programme Manager : Prince 2, MSP, Agile

23 against the Trainers: training qualifications. Clinical Coders: NCCQ. Informatics workforce: ITIL UKCHIP EQAS recognised course Technicians: specialist qualifications; e.g. Microsoft, ITIL is highlighted in bold font 4.7 Staff within the Service have an agreed up to date, documented Personal Development Plan (PDP). The denominator (d) is the number of staff in post as of the most recent report (where possible data is less than 6 months old). The numerator (n) is the number of staff with a PDP. d divided by n X 100 = percentage A - 100% B % C % D - Less than 50% A=4 B=3 C=2 D=1 4.8 The Service identifies key staff members who possess critical or senior s of skill or expertise, and takes steps to future-protect the service in case of early or unexpected departure or loss of those individuals. Critical can be defined as essential to the running of the service or part of the service. plans, reports, meeting, examples of where plans have been applied. A - There are documented plans in relation to all key individuals or services that are critical to the Service and all customers. The plans are systematically reviewed. B - There are documented plans in relation to specialists only. The plans are systematically reviewed. C - No plans are in place or not routinely applied. A=3 B=2 C=1 4.9 Staff within the Service complete an induction programme within six months of being in post which includes gaining an understanding of both internal and external customers Learning opportunities available to all staff within the Service. The denominator (d) is the number of new starters in last 12 months from date of completion. The numerator (n) is the number of new starters that have experienced an induction programme. d divided by n X 100 = percentage A - 100% B % C % D - Less than 50% A=4 B=3 C=2 D=1 No 2 This could include courses, mentoring, action learning, networking, job shadowing and academic qualifications. A - All staff have equal access to, and are encouraged to make use of, internal and external learning opportunities. These experiences are A=4 B=3 C=2 D=1

24 against the data from a learning management system, from education, training & development meetings, course bookings, reports showing priority areas for development drawn from PDP process, SOCITM professional activities is highlighted in bold font always linked to the PDP process and there is systematic liaison with training staff to identify learning needs and provide the means to meet these. B - All members of staff are encouraged to make use of inhouse learning opportunities and there is evidence of all s of staff accessing external opportunities. Some linkage to PDP process and training staff. C Learning opportunities are available to all s of staff but are specifically related to informatics rather than generic opportunities and/or is mainly on-the-job with limited evidence of a systematic approach to provide staff at all s equal access to such learning. D- Nothing available and/or individuals are rarely given time off for personal development The Health Informatics Career Framework (HICF) or other structured approach is used to support workforce planning and development. case studies, policies, reports, evidence of partnership working with human resources, individual career plans based on HICF. A - The HICF or a similar approach is used comprehensively on a regular basis, with evidence of linkage with workforce planning. B The HICF or a similar approach is regularly used by managers for specific roles. C - The HICF or a similar approach is occasionally used; e.g. with new starters only. D - There is evidence that the Service intends to use a framework but this is not yet implemented. E - The HICF or a similar approach is not used at all. No 1

25 SECTION 5 SERVICE DELIVERY The Service Delivery section is designed to highlight service delivery areas. Efficient service delivery is a key indicator of a successful health informatics service and is an area of key interest and focus from a customer perspective. Ref Standard Guidance and examples of against the SLA and KPI Performance is highlighted in bold font 5.1 Service agreements (or equivalent) are reviewed and maintained year on year. 5.2 Formal processes and measures are in place and these identify the Service s key performance objectives in relation to customer requirements. The processes are regularly monitored and, as required, revised. written documentation of service reviews and their outcomes. a comprehensive set of KPIs generated by, and agreed with, the customer together with monitoring data that is reviewed on a regular basis. A - SLA (or equivalent) service description and s are reviewed frequently; e.g. monthly, bi-monthly or quarterly, and include operational, qualitative and quantitative aspects of the service. B - As A but reviewed annually. C - SLAs (or equivalent) service description and s are not regularly or systematically reviewed, and/or the review does not directly affect service structures or processes. D - No review of SLAs (or equivalent) service description and s takes place. A - Measures incorporating key performance indicators are used to identify all internal and external customers requirements, and systematically reviewed on a regular and frequent basis (i.e. more than annually). B - Measures incorporating key performance indicators are used to identify all internal and external customers requirements and systematically reviewed on an annual basis. A=4 B=3 C=2 D=1 A=4 B=3 C=2 D=1

26 against the Green IT is highlighted in bold font C - Measures are used to identify some customers requirements but the approach is unsystematic and/or key performance indicators are imprecise. D - No measures are in place to identify the Service s key performance objectives in relation to customer requirements. 5.3 The Service is active in implementing Green IT strategy/strategies Service Desk a plan, processes, documented agreement with customers, meeting, reports. (Section 3 of these s covers green strategy; this covers implementation of the strategy). A There is active inclusion of a green agenda in routine operational processes and procedures, with proactive leadership of the agenda within host and customer organisations. B Inclusion of a green agenda in routine operational processes and procedures takes place in own or host organisation only. C Inclusion of a green agenda in routine operational processes and procedures takes place when required or requested. D - Working towards the development of plans but currently no clear evidence of implementation. E Not active. B=5 No The Service Desk has formal accreditation through a recognised scheme. For example, NHS Connecting for Health Service Desk Accreditation or National Computing Centre IT Department Accreditation. certificates, reports and materials A There is national accreditation with NHS Connecting for Health and/or other nationally recognised external/3rd party s, and Level 3 or higher of the NIMM Service Desk Capability Assessment has been achieved. No 2

27 against the being prepared for accreditation. is highlighted in bold font B - There is national accreditation with NHS Connecting for Health and/or other nationally recognised external/ 3rd party s. C - Working towards formal accreditation, completed the initial self-, and has been successfully assessed against 80% or more of the criteria. D - Working towards formal accreditation, completed the initial self, and has provided some evidence for review (but not successfully assessed against 80% or more of the criteria). E - No formal accreditation. 5.5 The Service Desk prioritises incidents using a methodology agreed with the customer incident records, management reporting, service management system reports, SOCITM best practice, ISO compliance, process documentation, knowledge base/known error extracts, major incident reports, knowledge base and staff training. A - The Service Desk prioritises incidents as Critical, High, Medium or Low, informed by negotiated prioritisation with the customer, and has a response time associated with those categories, a and a of current performance that is reviewed and routinely published, and shared on a regular basis. B - A response time is associated with incident categories informed by negotiated prioritisation with the customer. There is a and a of current performance that is reviewed and routinely published, and shared on a regular basis. C - Incidents are prioritised, with evidence of some negotiated prioritisation with the customer, have associated response times and systems to measure against those A=4 B=3 C=2 D=1

28 against the 5.6 A high percentage of Service Levels and Service Requests are consistently achieved. Infrastructure For example, to identify number of breaches. logs, reports. is highlighted in bold font s but are not routinely published or shared. Standards may exist for incidents only. D - Incidents are not prioritised. A - 99% - 100% B - 95% - 98% C % D - Less than 75% A=4 B=3 C=2 D=1 No The Service follows an ITILaligned (or equivalent) Incident Management process to ensure the restoration of normal operations as quickly as possible with the least possible impact on either the business or the user. documented process, logs and Management Information reports. A - The organisation has a mature, documented and consistently followed Incident Management process covering Incident Management & Major Incident handling as per the ITIL framework, using the help desk as the single point of contact for all incidents. There is a capability for users to log incidents by means other than telephone ( , portal). The process will include reference to all of: incident reporting recording prioritisation classification management to resolution escalation to next support escalation to management two stage incident closure The process must be interfaced to other relevant service management processes including: problem management change management configuration & asset

29 against the is highlighted in bold font management There should be access to an up to date knowledge base with information on all of previous incidents related problems known errors workarounds. There is clear segregation of duties between the help desk and next support. There is an identified process owner for the Incident Management process. The performance of the process is routinely measured using key performance indicators including incident answer time and fix time, trends are analysed and remedial action taken if required. B - The process is documented and consistently followed but excludes up to two of the requirements set out in A above. C - There is an Incident Management process that is documented and consistently followed but excludes three to five of the requirements set out in A above. D - Follow basic principal, but no evidence of documentation or links to other processes, or if documented is not always followed. E - No 5.8 The Service follows an ITIL aligned (or equivalent) problem records, management A - The organisation has a mature, documented, and consistently followed No 2

30 against the Problem Management process to establish and remedy the root cause of incidents, and prevent their re-occurrence in order to minimize the impact of incidents on the organisation (s). information reporting on problems, Incident trend analysis, Service Management Systems, Process documentation, Problem Reviews, Known errors, related Change & Release Management records is highlighted in bold font Problem Management process. Proactive Problem Management is in place utilising all of: incident trend analysis routine reviews of suppliers problem lists other systems to identify potential problems in advance, allowing the service to address these before Incidents occur Root cause analysis techniques are in place (e.g. Fault tree Analysis, Kepner Tregoe Problem Analysis, 5 why s) to analyse problems. Problem records are routinely created for all incidents with an unknown root cause. A known error database is utilised and linked to the Incident Management process. Errors are managed until the fix has been developed. Interfaces to other ITIL processes are in place including: release management change management incident management configuration & asset Management IT service continuity management. Major Problem reviews take place for all Problems arising from high severity incidents. The performance of the process is routinely measured using key performance indicators including incident answer time and fix time, trends analysed, and remedial action taken if required.

31 against the is highlighted in bold font B - The process is documented and consistently followed but excludes up to two of the requirements set out in A above. C - There is a process that is documented and consistently followed but excludes three to five of the requirements set out in A above. D - Follow basic principal, but no evidence of documentation or links to other processes, or if E - No 5.9 The Service follows an ITIL aligned (or equivalent) Change Management process to ensure all changes are recorded, assessed, approved, and reviewed in an appropriate and controlled manner. change Management Documentation (RFC s, FSC, Change Review records), Management Information Reporting on Changes, Service Management System records, Process documentation. Links to Release Testing documentation. A - The organisation has a mature, documented, and consistently followed Change Management process, with a scope that includes all Changes to live systems. There is a Change Management Policy that defines the types of Change (Normal, Emergency, and Standard) and acceptable Change Authorities for different types of Changes. All Changes are : recorded filtered classified have a defined and documented scope assessed for risk and impact approved/rejected Implemented verified and signed off Risk and impact is assessed using a consistent matrix. Assessment and approval is done at an appropriate according to the Change No 1