Organisational Development Strategy

Transcription

1 Organisational Development Strategy Version Number: 3.1 Name of originator/author: Assistant Director of Organisational Learning and Development Name of responsible Workforce and OD Committee committee: Name of executive lead: Debbie Hodkinson Date V1 issued: July 2010 Last Reviewed: October 2013 (vers 2) April 2014 (vers 3) Next Review date: October 2016 Scope: Trust wide MMHSCT Policy Code Page 1 of 20

2 Document Title / Ref: Document Control Sheet Organisational Development Strategy Lead Executive Debbie Hodkinson Director Author and Contact Number Assistant Director of Organisational Learning and Development Type of Document Strategy Broad Category Broad Document Purpose The Trust s vision is to improve and enhance mental and physical health and well-being, facilitate personal fulfillment and help people to make a positive contribution to their communities. Scope Trust Wide Version number 3.1 Consultation LDSG Jan 2014, Workforce and OD Committee Feb 2015 Approving Committee Workforce and OD Committee Approval Date Feb 2015 Ratification and Date Trust Board Date of Ratification: October 2013 V1 Valid from Date July 2010 Current version is valid from approval date Date of Last Review October 2013 Date of Next Review October 2016 Procedural Documents to be read in None conjunction with this document: Training Needs Analysis Impact There are no Training requirements for this procedural document Click here to enter text. Financial Resource Impact There are no Financial resource impacts Click here to enter text. Document Change History Changes to this document in different versions must be detailed below. Rationale for the change should also be given Version Number / Name of procedural document this supersedes Vers 3 Type of Change i.e. Review / Legislation / Claim / Complaint Removal of Behavioural Accountability Framework due to outcome of Task and Finish group Date Feb 2015 Details of Change and approving group or Executive Lead (if done outside of the formal revision process) Debbie Hodkinson work External references used in the creation of this document: If these include monitoring duties upon the Trust for this policy the specific details should be recorded on the Monitoring and Compliance Requirements sheet Privacy Impact N/a Any issues? Choose an item. Assessment submitted Fraud Proofing submitted N/a Any issues? Choose an item. If not relevant to this procedural document give rationale: Page 2 of 20

3 Policy authors are asked to consider each of the nine protected characteristics under the Equality Act We expect you to demonstrate that throughout the policy process you have had regard to the aims of the Equality Duty: 1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Act; 2. Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and 3. Foster good relations between people who share a protected characteristic and people who do not share it. Please provide a brief account of how you have done this, further work to be completed and any support you have had in considering the aims and working in compliance with the Equality Duty. If you are unclear on how to do this or would like further advice and support then you may contact quality.admin@mhsc.nhs.uk. It is the responsibility of the approving group to ensure this statement reflects the Trusts objectives and position with compliance as set out within the NHS Equality Delivery System The Strategy is broad and the scope is Trustwide so complies with the Trust s Equality Delivery System. In line with the Trust values we may publish this document on our External Website. Is there any reason you would prefer this is not done? None It is the Authors responsibility to ensure all procedural documents comply with the Trust values If you are unclear on any of the requirements in the document control sheet then please quality.admin@mhsc.nhs.uk before proceeding Page 3 of 20

4 Monitoring and Compliance Requirements Sheet For audit, Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors, Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis. Procedural Document Title: Organisational Development Strategy Does this procedural document offer support or evidence for the Trusts registered activities and outcomes? Yes Primarily Additional Not Applicable Additional Is this an NHSLA Document? No Which Standard does this relate to? Which Criterion Not Applicable Choose an item. Choose an item. If other Monitoring requirements are necessary i.e. Health & Safety Act and you should include them here and record them in the External References section Specify where the requirement originates Minimum Requirement / Standard / Indicator to be monitored & Section of document it appears Process for monitoring Responsible Individual / Group Additional Details i.e. Section number, Code of Practice Frequency of Monitoring Audit Yearly Audit Yearly Audit Yearly Audit Yearly Responsible Group for review of results / action plan approval / implementation Comments NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected timescales for completing the audit to quality.admin@mhsc.nhs.uk as soon as possible and no later than 4 weeks prior to the audit commencing. The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate. Page 4 of 20

5 Contents Page Section Title Page Number 1 Introduction 6 2 Successes so far 6 3 Organisational approach 7 4 Present Culture 8 5 Future State 8 6 Key Focus Areas Implementation 11 8 Monitoring and Evaluation 11 Appendix 1 Strategic Action Plan Have you considered using a flowchart in your document to provide easy reference for staff? If you need support in developing a flowchart contact quality.admin@mhsc.nhs.uk Page 5 of 20

6 Organisational Development Strategy Introduction 1.1 The Trust s vision is to improve and enhance mental and physical health and well-being, facilitate personal fulfillment and help people to make a positive contribution to their communities. In order to achieve this vision, a focus on a number of key areas is essential to build on the successes of the Organisational Development Strategy Organisational development (OD) is defined as a structured intervention designed to change an organisation so that it is capable of achieving agreed corporate objectives OD does not just happen; it can be described as the journey that makes an organisation fit for purpose. It is about taking proactive steps to ensure individuals, teams and the organisation as a whole function better and involves continuous and sustained effective change management, leadership and improvement over the long term OD involves fostering a culture of quality, high performance and excellence by providing the infrastructure for development and specific interventions that support staff to achieve both their and the aims and objectives of the organisation. In practice, organisational development is about taking deliberate planned steps to create an organisational environment that enables staff to understand and deliver the organisation s objectives. 1.3 The Organisational Development Strategy will support the delivery of the Trust s strategic objectives by enabling continuous ongoing improvement. The strategy provides a framework and an associated action plan to facilitate ongoing change through workforce development, supporting staff to deliver quality patient care which optimises opportunities for recovery and continued improvements to service users experience. 1.4 The NHS Constitution establishes the principles and values of the NHS in England, setting out the rights to which patients, the public and staff are entitled, pledges the NHS is committed to achieve, along with responsibilities which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. NHS bodies are required by law to take the Constitution into account in their actions and decisions and this strategy embraces this commitment. 1.5 The recommendations of a number of key reports will be embodied into actions in order to put quality, safety and service users at the heart of organisational development. 1.6 After a brief outline of our achievements so far, a summary of the present state and a portrayal of our expectations for the future, the focus areas for the next three years are described along with their links to the Trust s values and desired behaviours. 2. Successes so far 2.1 The Organisational Development Strategy focused on five outcomes to achieve the Trust s strategic objectives. These were: Engagement, Participation and Involvement Workforce and Capacity Learning and Development Leadership and Management Styles, Processes and Systems Page 6 of 20

7 Equality and Diversity Engagement, Participation and Involvement Achievements include: Appointment of Director of Communications Communications strategy in place Patient stories included at each Board meeting Service user involvement strategy in place Chief Executive blogs Leadership Forum meets monthly Workforce and Capacity Achievements include: Star awards annually to recognise staff achievement nominated by staff Employee of the month to recognise staff achievement - nominated by staff Establishment control panel (ECP) weekly to consider vacancies and appointments Learning and Development Achievements include: Centralised training budget established to fund staff development Elearning initiated to enable flexible access to mandatory training Vocational development diploma in place including functional skills Appraisals aligned with annual business plan Recovery Education established - service users co-produce and co-deliver training Service users have received teacher training to deliver courses Leadership and Management Styles, Processes and Systems Achievements include: Leadership and management development programme delivered Leadership Forum established led by Leadership Forum Steering Group Operational restructure enacted within In-patients and Community Services Equality and Diversity Achievements include: Single Equality Framework in place Single Sex accommodation established 3. Organisational approach 3.1 In March 2013 the Chair of the Trust Board commissioned an independent evaluation of the organisation in respect to two significant areas: The organistional uncertainty during the transition period being experienced The organisational culture, particularly the impact on staff morale, leadership and empowerment. Page 7 of 20

8 4 Present Culture 4.1 The Singleton Report findings highlighted specific areas of concern relating to staff morale, the culture and ways of working; the future of the organisation and its relationship with its partners. This OD Strategy focuses on initiatives to address the issues of staff morale, culture and ways of working. 4.2 The Singleton Report findings endorsed recent years staff survey results and subsequent action plan themes. Key themes identified by staff in 2012 to improve staff engagement included: Everything being finance driven Paperwork / reporting overload Chasing Foundation Trust status Workload and resources Beds Organisational change and job security Poor communication Poor management / leadership Employee recognition Estates and infrastructure Priority areas further to the 2013 staff survey additionally included the quality of appraisals and not being involved in changes affecting work. 4.3 In order to ensure continued relevance and gauge improvements, a quarterly survey was undertaken during the first two quarters of 2012/13 preceding the 2012/13 national staff survey in the third quarter. The results of the 2012/13 survey indicated that whilst some improvements had been made, performance was worse over a number of question areas indicating that there had been little change in staff engagement when compared to the 2011/12 results. In addition, the Trust s response rate had decreased as compared to other mental health trusts which provided an additional source of information regarding engagement. 4.4 Given that recent staff survey results have highlighted limited change in staff engagement, this strategy acknowledges the results to be the current indicator of culture and engagement within the Trust and the basis for future improvement alongside the Singleton Report findings. The Organisational Development Strategy aims to create and develop the conditions under which the highlighted themes and associated outcomes will be delivered. 4.5 A national focus on care quality with a strong emphasis on putting patients first instigated by the Francis Report (2013), the National Nursing Strategy s 6Cs (care, compassion, competence, communication, courage, commitment) along with the Keogh Review (2013), Berwick Report (2013) and Cavendish Review (2013) are also significant influences on the Trust and the work to be undertaken to build the culturally responsive, quality focused and performance orientated climate required to sustain the organisation in the future. 5. Future state 5.1 An organisational culture needs to be owned by staff and agreed values and behaviours which are relevant to the Trust s strategic aspirations enacted in practice. Mindful of this and the current state described, the following features of an ideal culture are aspired to: A high level of staff morale Page 8 of 20

9 A recovery focused philosophy which puts service users and carers first Service users and carers contribute to the services they receive and the development that service users and staff receive Compassion in practice as embraced by the 6Cs is demonstrated by all staff The concept of Intelligent Kindness is endorsed to focus goodwill and inspire and direct the efforts of people and organisations towards building relationships with service users to positively affect their well-being Values and behaviours drive the quality of care in terms of providing a positive experience and reducing harm Competent and capable staff, teams and leaders are equipped and empowered to lead and deliver effective services The potential of staff is liberated and staff are valued for their contribution Leadership and management development meets staff and business needs and a structured approach to succession planning is established Learning and development activity is fully aligned to the Trust s business needs and aspirations Continuous improvement approaches are enacted to facilitate innovative, efficient, effective service delivery A business engaged, performance ethos underpinned by personal responsibility and accountability is developed and sustained Poor practice is actively addressed by approaches based on support and continual improvement as well as effective appraisals and development The building and sustaining of effective partnerships and collaborations Communication systems are two way and transparent Organisational change is managed well and communicated to staff in a timely way Workforce planning effectively informs the implications of organisational change and cost improvement schemes Estates and IT strategies are linked with service delivery and staff development and performance requirements 5.2 A focus on the requisite systems and processes as well as an understanding of the required behaviours and what constitutes a successful outcome is acknowledged as being fundamental to achieving the outlined desired future state. 5.3 Further to the Francis Report (2013), Keogh Review (2013), Berwick Report (2013) and Cavendish Review (2013) organisational development is predicated on investing in staff at all levels to build capacity regarding the application of quality control, quality improvement and quality planning methods to focus on patient safety The Organisational Development Strategy recognises the contribution of the Management Framework in both providing assurance that performance is managed, and enabling the Trust to articulate its strategy and identify key performance indicators. This strategy also recognises the interdependencies between business planning and service, team and individual development, and aims to ensure that these remain aligned in order that quality, safety, performance and development agendas are able to work together to improve services and service user experience. 5.5 Supporting leaders in their development is a requirement so that they may mobilise resources and practices towards the achievement of particular outcomes and focus on quality and reducing harm. 5.6 Staff should be supported to do their work, treated with respect and appreciated for what they do. Page 9 of 20

10 6. Key focus areas Key themes linked to the Trust values of Truthfulness, Respect, Understanding, Standards and Togetherness and the Trust s strategic objectives have been used to outline key actions and expected outcomes. The focus areas have been derived from the Singleton Report and a number of associated focus groups / events to elicit and validate details, the staff survey results and an earlier version of the OD Strategy (Organisational Development Strategy ). The actions have been grouped into 30, 60, 90 and 90+ day timeframes. 6.2 A behavioural framework was developed by staff to underpin the Organisational Development Strategy. The framework involved rating a number of TRUST values-based behaviours linked to role / band. The quality and performance focused behaviours had been mapped to a number of frameworks including KSF. This approach was further refined during a review of the Personal Review (formerly Appraisal) process in order to ensure a constant rather than purely annual focus on required values and behaviours. 6.3 Building on the achievements noted in section 2, the following values and key focus areas are outlined. These will be achieved via expected behaviours to deliver required outcomes and are outlined within the strategic action plan (see appendix 2) Truthfulness (putting patients first): Maintaining an honest and open dialogue with staff and service users to ensure that quality of care, transparency and honesty underpin all our actions. This requires the need to ensure that lessons learned (both positive and negative), routinely inform staff development and are both shared and embedded into practice. In addition, the appraisal system and content needs to ensure that conversations are meaningful, result in development needs being identified and incorporate discussion regarding required organisational behaviours alongside role required competencies Respect (empowering staff): Valuing people service users, carers and staff respecting dignity and tailoring services to individual need. This focuses on actions in relation to staff establishing how we do things round here in order to create an organisational culture which enhances staff morale as well as achieves organizational business. It also concerns trusting staff to do their jobs by empowering them at all levels. These actions will be achieved by embedding respect and associated behaviours into organisational culture and by appreciating and valuing Trust staff Understanding (supporting research and delivering growth): Committed to understanding individual needs; to continuously extending our knowledge and skills so that the latest teaching and practice remain at the heart of our service development. To achieve this, the organisation requires leaders who are able to influence culture, perform highly, innovate and shape services at all levels of the organisation, whilst recognising the potential of others and having the systems and processes to facilitate managing this potential. Individuals and teams need to access development which will help them to fulfil their roles and responsibilities to the highest standards Standards (ensuring quality): Setting the highest standards of professionalism, safety, security and confidentiality in all that we do. This will be achieved by ensuring clarity regarding the Trust s vision and strategy and investing in improved resources, systems and equipment. This will ensure that provision is led by service requirements and is fully inclusive of legal and well-being factors in order to support a positive experience for staff and those who receive our services Page 10 of 20

11 6.2.5 Togetherness: Actively fostering partnerships, so that services can be fully integrated to optimum effect. This involves developing systems and processes to engage and communicate with staff to share information, gain feedback and seek involvement in decision making. It also concerns appreciating staff and reviewing recognition arrangements 6.3 The relationship between the Trust s values, behaviours and outcomes is illustrated below. Values Behaviours Truthfulness Respect Understanding Outcomes Standards Togetherness 7. Implementation 7.1 A strategic action plan will accompany the strategy (see appendix 1). This will highlight specific actions, their delivery, lessons learned and expected outcomes. 7.2 Actions to address each item will be developed and implemented by a named senior Lead. 8. Monitoring and evaluation 8.1 Monitoring and evaluating progress is essential to the success of this strategy in order to deliver sustainable change. The Executive Management Team will take overall responsibility for driving the strategy. 8.2 Progress of the strategy via the associated action plans will be monitored through the bi-monthly Workforce and Organisational Development Committee. Quarterly reports will be produced for Trust Board. Page 11 of 20

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13 Appendix 1 Phase 1 immediate actions (30 Days April) Creating a 2 Year Strategy Staff Comment Lead Director (Sponsor) Outcome 8 9 Provide clarification on the Trust vision /strategy & its relationship with other sub strategies / plans Clarify how the Annual Business Plan and objectives relate to staff. Abandoning 'blame as a tool' Director of Strategy, Transformation and Project Manager Chief Executive The Trust Vision is clear and explained to staff. Staff are clear about the ABP and their role in delivering the objectives. 10 Develop a staff charter from the behavioural framework which includes a description of expectations & counter behaviours identified through staff focus group/compact group. Assistant Director of Organisational Learning & Development & Deputy Director of Director of A Staff Charter in place produced by staff detailing explicit required behaviours and expectations at all levels. 11 Implement the behavioural framework and staff charter by rolling out through existing & stand alone events. Assistant Director of Organisational Learning & Development & Deputy Director of Director of Staff Charter is signed up to and displayed in each working area 12 Increase limit for budget holders and nominated deputies to sign off invoices, purchase orders, etc. from 300 to 1,000 Head of Financial Services Director of Finance Additional restrictions removed and the Scheme of Delegation levels in the Standing Financial Instructions reinstated. 13 management by exception & to include the celebration of good performance. Listening to Staff & Service Users more Director of Strategy, Transformation and Exception reporting at approach at Management meetings in place. Trust wide communication celebrating good performance. Page 13 of 20

14 14 Creation of a physical communications board / "post-it" / virtual wall for service areas which also allows feedback from teams, staff views & service development information. Head of Communications Director of Communications, Engagement and Partnerships Identification & implementation of Communication champions, responsible for the display of key messages on appropriate communication notice boards Team Brief reinstate and include a feedback mechanism for staff to comment / feed back Monthly Staff News reinstate to include good news and 'what s happening in your areas'. Review all communication mechanisms including the use of purely electronic methods. Weekly / message about what we have done, sharing both good and bad news Review of communications language to ensure plain English is used. General Meetings - Draw up meetings protocol establishing behaviours and issue Trust wide Team Meetings - Monthly mandated & audited, with standard agenda items and feedback loop twoway. s - Draw up an protocol which includes the addressing of cc and bcc, categories of message (e.g. for action, info / sharing, important), the ability to follow special interests (RSS feeds) and considers the possibility of free time to allow conversations instead. Issue Trust wide Head of Communications Head of Communications Head of Communications Head of Communications Head of Communications Director of Communications, Engagement and Partnerships Director of Communications, Engagement and Partnerships Director of Communications, Engagement and Partnerships Director of Communications, Engagement and Partnerships Director of Communications, Engagement and Partnerships Monthly Team Brief produced, circulated and shared via Team Meetings. Staff News produced & circulated. More targeted communications which allow staff subscriptions. in place Communications in plain English Board Secretary Director of Meeting protocol developed, shared and implemented Deputy Director & Deputy Chief Operating Officer Head of Communications Director of and Interim Director of Operations Director of Communications, Engagement and Partnerships Team Meeting Agenda developed, including key items, shared and implemented. protocol produced and implemented. Improving Signals from Leaders 23 Review and agree the Board Development plan which addresses feedback from the Singleton Report & Staff Survey & reflects staff developed behavioural framework. Director of Chief Executive Board Development plan in place, which includes success criteria. Page 14 of 20

15 24 Executive Directors/ NEDs to visit night staff and undertake a shift each in services (rolling sleeves up). Chief Nurse & Director of Quality Assurance & Interim Director of Operations Chief Executive Timetable in place for Executive Directors/ NEDs to visit night staff. Timetable in place for Executive Directors/ NEDs participate on a shift in clinical services. 25 Cancel Leadership Walks in their current form and introduce new means of informal and supportive engagement by visits from Execs & NEDS to services (rolling sleeves up). Non-exec directors (NEDs) to move from inspection of services approach to support and engagement. Chief Nurse & Director of Quality Assurance Chief Executive Leadership walks cancelled. Improved staff experience of Board visits. Listening to Staff & Service Users more 26 Corporate service staff to arrange to work in clinical service setting to improve understanding of services and vice versa. Deputy Director of Interim Director of Operations Timetable in place for clinical & corporate staff buddy arrangements. 27 Commit to pledges to make a difference - 'what small change I will do to improve working lives for me / others'. Head of Communications Director of Staff make pledges Investing in Continuous Improvement 28 Ensure that 'lessons learned' inform staff development. Assistant Director of Organisational Learning & Head of Patient Safety Director of, Chief Nurse & Medical Director Staff development needs are routinely informed by lessons learned and embedded into practice. 29 Streamline the complaints and enquiries process Head of Patient Experience Chief Nurse & Medical Director Lean complaints and enquiry process Phase 2 intermediate actions (60 days May) Investing in Continuous Improvement 30 Review the appraisal/ PADR system & process and integrate the behavioural framework. Assistant Director of Organisational Learning & Deputy Director of Director of, Chief Nurse Agreed appraisal systems in place, staff training provided. Creating a 2 Year Strategy Page 15 of 20

16 31 Estates Review work areas including air conditioning and windows which open Head of Estates Director of Finance Review of environmental factors within workplaces, with clear feedback to staff of possible improvements & rationale for any delays/inaction. 32 Improve staff rest areas Head of Estates Director of Finance Review of environmental factors within workplaces, with clear feedback to staff of possible improvements & rationale for any delays/inaction. IT 33 Ensure that staff have equipment (laptops/tablets/printers) which support being able to do the job. Review and reallocate all single office printers where a network printer is available. Associate Director of IT Review of equipment within workplaces, with clear feedback to staff of possible improvements & rationale for any delays/inaction Intranet Search needs improving Update & cleanse address book (remove leavers) & create an address book for our partners (CCG & MCC etc) Associate Director of Informatics Associate Director of IT Improved intranet search capacity. Updated & cleansed address book & creation of address book for our partners 36 IT training more available / accessible courses Associate Director of Informatics Identify training requirements and provide increased IT training where possible & rationale for inability to provide. Resources 37 Admin support 1. to ensure that there is consistent provision and access to. 2. Completion & communication of admin review. 3. Practitioner admin support to increase time delivering care and reduce administration burden. Deputy Chief Operating Officer Interim Director of Operations & Chief Executive Completion of admin review, with clear communication of the outcome. Review of admin capacity ensuring consistency and where practical reducing admin burden on clinical staff. 38 Staffing levels being reviewed and considered by Chief Nurse. Evaluation, results & outcome to be shared. Head of Professions Chief Nurse, Medical Director Staffing levels reviewed. Evaluation, results & outcome shared with all staff. Abandoning 'blame as a tool' Page 16 of 20

17 39 40 Further develop 6 Cs Just Do It campaign as means of empowering staff at all levels Progress paperwork audit and communicate recommendations as identified Head of Nursing Director of & Chief Nurse, Director of Quailty Assurance Chief Nurse & Medical Director Chief Executive Just Do It' campaign further developed and rolled out ensuring 6C's are embedded. Paperwork audit complete & recommendations published All managers commit to regular 1-2-1s which focus on the individual Deputy Director & Deputy Chief Operating Officer Director of and Interim Director of Operations All staff receive regular 1-2-1s. Supervision to be provided (regular and consistent) Head of OT Chief Nurse, Medical Director All staff receive regular & consistent supervision. Listening to Staff & Service Users more Development of Staff Forums (learning from services such as Psychology where this is already in place). Assistant Director of Organisational Learning & Development & Deputy Director of Director of & Director of Communications, Engagement and Partnerships Staff Forums in place Change Champion role considered and developed as appropriate. To acknowledged and appreciate staff achievement through the review of recognition arrangements and development of menu of approaches. Director of Strategy, Transformation and Assistant Director of Organisational Learning & Development & Deputy Director of Director of & Director of Communications, Engagement and Partnerships Role of Change Champions considered and developed as appropriate. Recognition arrangements reviewed and options menu implemented. Impact of revised approach to be measured through temperature checks and staff survey Opportunity to Shadow Executives Use Staff Friends and Family Test (SFFT) mechanism to temperature check staff morale Executive Assistant to Chief Executive and Chair Development & Deputy Director of Chief Executive Director of Establish mechanism for staff to shadow directors. Review & communication of 1/4ly SFFT results. Page 17 of 20

18 Phase 3 longer term strategies (90 days June onwards) Improving Signals from Leaders 48 Review Management Development and Leadership requirements and provision, including clinical leadership Development & Deputy Director of Director of Fit for purpose management development programme, resourced. 49 Establish staff amenity budgets (up to 100 per team) or introduce Development Fund for internal bids Head of Financial Management Director of Finance Establish a staff amenity budget Review the leadership forum, including content and participants. Progress changes/actions identified by the paperwork audit. Leadership Forum Steering Group Chief Nurse & Director of Quality Assurance Director of Communications, Engagement and Partnerships Director of Leadership Forum reviewed. Provide a regular update on progress & changes implemented. Listening to Staff & Service Users more 52 Develop regular interface/stronger links with BME and hard-to-reach communities Head of Patient Experience Chief Nurse & Director of Quality Assurance & Interim Director of Operations & Director of Review of Equality & Diversity Policy and associated actions, ensuring opportunities to engage hard to reach communities are supported. 53 Workforce health & wellbeing review of current activity and consideration of further initiatives and resource requirements. Deputy Director of Director of Workforce Health & wellbeing strategy reviewed with initiatives and resource requirements identified. 54 Roll out of staff service improvement engagement forums modelled on existing good practice. Strategic Programmes Manager Roll our of forums for staff to provide views and feedback on service improvements. Investing in Continuous Improvement 55 Review of Mandatory Training, including rationalising face-to-face and electronic provision with a focus on Quality versus Quantity Assistant Director of Organisational Learning & Development, Heads of Professions, Director of Medical Education Director of, Chief Nurse, Medical Director Mandatory Training review concluded. Page 18 of 20

19 56 Promotion & communication of Lean training and increased wider organisational understanding & knowledge. Strategic Programmes Manager Staff understand basic lean principles and are supported to implement this approach in their work. Reduction of waste and duplication is evidenced. 90 days+ Care group Governance meetings to review patient safety incidents and report learning and actions via the Integrated Risk Management and Clinical Governance Committee. Lessons learned to be reported as per the PHASE 1 action / comment. Review of the current root cause analysis techniques with the identification of the preferred approach. 57 Deputy Chief Operating Officer, Head of Patient Safety, Head of Patient Experience. Chief Nurse & Medical Director Patient safety incidents are satisfactorily feedback to patients, staff and families improving patient experience. Staff trained in the identified and preferred Root Cause Analysis method(s), which is utilised consistently. 58 To establish and embed a recovery focused philosophy of care to underpin high quality care provision which puts the patient first. Heads of Profession Chief Nurse & Medical Director Improvement in service user experience/satisfaction. Improved clinical outcomes, with a consistent reduction in length of stay. 59 Develop and embed shared care protocols and an effective collaborative care planning approach. Heads of Profession Chief Nurse & Medical Director Shared care protocols and collaborative care planning approach in place Implement a service led estates strategy which is fully inclusive of Dignity and Equality Act requirements. Developing teams and individuals using evidence based / best practice approaches to address skill gaps and better equip teams to support staff to deliver high quality services. Evaluate the quality and impact of development programmes and service developments to ensure that safety, harm reduction and lessons learned are at the heart of service provision. Head of Estates Director of Finance Integrated estates and service strategy which are compliant with the Equality Act Assistant Director of Organisational Learning & Development Assistant Director of Organisational Learning & Development Director of Director of Each services has a development plan supported by individual PDPs. Patient centred care plans are in place for all patients. Staff development needs are informed by lessons learned and lessons learned are routinely embedded into practice. Page 19 of 20

20 63 Ensure that staff meet the required levels of literacy, numeracy and IT skills in line with their roles, responsibilities and national requirements Assistant Director of Organisational Learning & Development & Associate Director of Informatics Director of & A standard level of functional skills to meet role requirements specified and in place. 64 Ensure that staff have role appropriate project management skills. Strategic Programmes Manager All Trust projects are developed on time and to budget. 65 Ensure that the Workforce Plan supports the identification of current and emergent workforce needs & demographics Deputy Director of and Heads of Professions. Director of, Chief Nurse & Medical Director Appropriate skill mix in place to meet service needs, where new and enhanced roles are operational and effective supporting the delivery of effective care pathways & new service models. 66 Implement a service led IM&T strategy which is aligned with current and future information and technological requirements Associate Director of IT Trust technological and information requirements are met, with the provision of timely information and appropriate IT equipment to support staff in their roles and service improvements. 67 To ensure compliance with all regulatory and statutory requirements. Head of Patient Safety Chief Executive All regulatory standards and requirements are met (NHSLA / CQC / Professional Codes of Conduct). NB: The source for the identified actions has been taken from the Singleton Report, Staff Survey results & OD Strategy. Trust Values & Annual Business Plan Objectives Truthfulness (Putting patients first) Respect (Empowering Staff) Understanding (Supporting research & delivering growth) Standards (Ensuring quality) Togetherness (Working in partnership) Page 20 of 20