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CYFARFOD BWRDD PRIFYSGOL IECHYD UNIVERSITY HEALTH BOARD MEETING

DYDDIAD Y CYFARFOD: DATE OF MEETING:

29 November 2018

TEITL YR ADRODDIAD: TITLE OF REPORT:

Mid Year Review of 2018/19 Annual Plan

CYFARWYDDWR ARWEINIOL: LEAD DIRECTOR:

Karen Miles, Director of Planning, Performance, Informatics & Commissioning

SWYDDOG ADRODD: REPORTING OFFICER:

Daniel Warm, Strategic Planning Manager

Pwrpas yr Adroddiad (dewiswch fel yn addas)

Purpose of the Report (select as appropriate) Er Gwybodaeth/For Information

ADRODDIAD SCAA SBAR REPORT Sefyllfa / Situation This report is intended to provide an update with regard to progress in the delivery of the University Health Board’s 2018/19 Annual Plan at the mid-year point, with particular reference to:

• Our financial position

• Our performance position

• The delivery of our actions plans supporting the 2018/19 Annual Plan

Cefndir / Background Following several discussions between the University Health Board (UHB) and Welsh Government (WG), Hywel Dda UHB is operating an Annual Plan for 2018/19. This report updates the Board on progress to date.

Asesiad / Assessment Financial position

• As per the Turnaround Update/Finance Update Report – Month 7 2018/19 to Board November 2018 (see agenda item 6.3), reported on a bi-monthly basis to the Board and to the Finance Committee.

• The UHB’s financial position at the end of Month 7 represented an adverse variance against plan of £0.9m (YTD). However, the UHB has achieved another breakeven position in-month.

• This position has been delivered through the use of non-recurring and one off adjustments totalling £4.9m in the year to date and £1.3m in month. The normalised monthly financial position deteriorated in month and represents a significant concern. The UHB is taking all necessary actions to identify non-recurring measures taken to support the in-year delivery; this is increasing the challenge for the delivery of future recurrent solutions and the UHB’s long term financial sustainability.

• Recognising the need for the delivery profile to increase significantly in order to achieve the full savings requirement, all directorates forecasting a year end deficit are being requested by the Chief Executive to produce a recovery plan to achieve breakeven. We are continuously looking for new schemes and validating existing schemes and as a consequence of work in Month 7 the current total stands at £35.5m. Although the plans are

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in excess of the savings requirement, the total forecast savings within the WG Monitoring Return remains at £30.7m reflecting the risk of non-delivery of an element of red schemes.

• The proportion of blue (those schemes started in 2017/18 and with no risk to delivery in 2018/19) and green schemes has marginally increased to £22.4m (63%), with £8.9m assessed amber (25%) and £4.1m as red (11%). £3.0m of schemes were delivered in Month 7.

• The UHB’s financial position in month, along with the profile of expected delivery of savings schemes, places a significant risk on the financial forecast for the yearend of £35.5m.

• While the use of non-recurrent measures has managed the financial position in the year to date, it is critical that the operational delivery of savings is accelerated in the remainder of the year to provide assurance that the forecast position is achieved.

Performance position

• As per the Integrated Performance Assurance Report (IPAR) – Month 7 2018/19 to Board November 2018 (see agenda item 6.5). The IPAR is presented to Board and Business Planning and Performance Assurance Committee (BPPAC) on alternate months. A summary of the performance status as at the end of October 2018 can be found at Annex 1.

2018/19 Annual Plan Action Plan position

• Progress against these action plans is reported on a quarterly basis to BPPAC and Welsh Government. The position at the end of Quarter 2 is:

Action Plan

Carmarthenshire County

Ceredigion County

Pembrokeshire County

Primary Care – overarching

Therapies

Radiology

Governance

Digital

Capital

Workforce and Organisational Development

Service Improvement

Research and Development

Clinical Audit

Cancer

Mental Health and Learning Disabilities

Pharmacy

Planned Care

Stroke

Unscheduled Care

Women and Children’s

Nurse staffing levels act

Quality and Safety – patient feedback

Quality and Improvement Framework implementation

Infection Protection and Control Improvement

Communication and Engagement

Welsh Language

Carers

Public Health Wales Act

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The current status as at Q2 shows that of the twenty-eight (28) Actions Plans, zero (0) are RAG rated as Red; nine (9) are RAG rated as Amber; seven (7) are RAG rated Amber/Green and twelve (12) are RAG rated as Green. As noted at the August and October 2018 BPPAC meetings, BPPAC members requested a more succinct report on progress for Quarter 2 by reporting on priority/impactful actions only and providing an audit trail on the rationale as to why the remaining actions were no longer to be reported on, even though they would still be progressed by Directorates. To address this request, as well as BPPAC concerns regarding a potential inconsistency in how RAG ratings have been attributed to individual actions and the overarching RAG status, Quarter 2 returns have now been revisited for priority / impactful actions only, plus a new RAG assessment (in line with that used by the Turnaround process) has been used as follows:

• Blue risk – no risk to delivery, 100% certainty to deliver

• Green risk – low risk to delivery, assumed to be able to deliver

• Amber risk – medium risk, actions required to mitigate risk to deliver

• Red risk – high risk, no achievement / unlikely to deliver For the most impactful actions for each of the 28 action plans, the RAG status for each is as per the table in Annex 2.

Argymhelliad / Recommendation The Board is asked to note the progress in the delivery of the University Health Board’s 2018/19 Annual Plan at the mid-year point, with particular reference to:

• Our financial position

• Our performance position

• Progress in the delivery of our actions plans supporting the 2018/19 Annual Plan

Amcanion: (rhaid cwblhau) Objectives: (must be completed) Cyfeirnod Cofrestr Risg Risk Register Reference:

Not Applicable

Safon(au) Gofal ac Iechyd: Health and Care Standard(s): Hyperlink to NHS Wales Health & Care Standards

All Health & Care Standards Apply

Choose an item. Choose an item. Choose an item.

Amcanion Strategol y BIP: UHB Strategic Objectives: Hyperlink to HDdUHB Strategic Objectives

All Strategic Objectives are applicable

Choose an item. Choose an item. Choose an item.

Amcanion Llesiant BIP: UHB Well-being Objectives: Hyperlink to HDdUHB Well-being Statement

Improve Population Health through prevention and early intervention Support people to live active, happy and healthy lives Improve efficiency and quality of services through collaboration with people, communities and partners Develop a sustainable skilled workforce

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Deddf Llesiant Cenedlaethau'r Dyfodol (Cymru) 2015 - Pum dull o weithio:

The Well-being of Future Generations (Wales) Act 2015 - 5 Ways of Working: Hyperlink to Well-being and Future Generations Act 2015 - The Essentials Guide

Please explain how each of the ‘5 Ways of Working’ will be demonstrated

Long term – the importance of balancing short-term needs with the need to safeguard the ability to also meet long-term needs. IMTPs/Annual Plans and their supporting documentation are intended to provide assurance on the long-term sustainability of services in delivering the priorities of Welsh Government, alongside ensuring delivery of services in the short-term.

Prevention – the importance of preventing problems occurring or getting worse The NHS Wales Planning Framework and therefore the IMTP/Annual Plan is predicated on a prevention and public health agenda.

Integration – the need to identify how the University Health Board’s well-being objectives may impact upon each of the well-being goals, on its other objectives, or on the objectives of other public bodies The Annual Plan 2018/19 supports and advances the University Health Board’s Strategic Objectives, mission statements and values/behaviours.

Collaboration – acting in collaboration with anyone else (or different parts of the organisation itself) which could help the University Health Board to meet its well-being objectives Services are planned depending on requirements with partners both within the University Health Board and externally, for example, with other Health Boards across Wales. The Annual Plan 2018/19 will ensure this objective is met.

Involvement – the importance of involving people with an interest in achieving the well-being goals, and ensuring that those people reflect the diversity of the area which the University Health Board serves The Annual Plan 2018/19 supports and advances the University Health Boards Strategic Objectives, mission statements and values/behaviours.

Gwybodaeth Ychwanegol: Further Information: Ar sail tystiolaeth: Evidence Base:

Included in the report

Rhestr Termau: Glossary of Terms:

Included in the report

Partïon / Pwyllgorau â ymgynhorwyd ymlaen llaw y Cyfarfod Bwrdd Iechyd Prifysgol: Parties / Committees consulted prior to University Health Board:

Business Planning & Performance Assurance Committee

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Effaith: (rhaid cwblhau) Impact: (must be completed) Ariannol / Gwerth am Arian: Financial / Service:

This is a key component in the delivery of the Annual Plan 2018/19

Ansawdd / Gofal Claf: Quality / Patient Care:

This is a key component in the delivery of the Annual Plan 2018/19

Gweithlu: Workforce:

This is a key component in the delivery of the Annual Plan 2018/19

Risg: Risk:

Risks will be assessed as part of the ongoing process of monitoring the Annual Plan 2018/19

Cyfreithiol: Legal:

As above

Enw Da: Reputational:

The University Health Board needs to meet the targets it has set out in individual plans to maintain its reputation with Welsh Government together with our stakeholders including our staff

Gyfrinachedd: Privacy:

Not applicable

Cydraddoldeb: Equality:

Consideration of equality legislation and impact is a fundamental part of the planning of service delivery changes and improvements

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Annex 1: Performance Position National Target

Position at Sep 2017

Position at Sep 2018

Sep ‘18 compared to Sep ’17

Position at Oct 2018

2018/19 Trajectories

Nov ’18

Dec ‘18

Jan ‘19

Feb ‘19

Mar ‘19

% Waiting < 26 weeks RTT 95% 81.09% 85% Improved 86.13% >86%

Waiting > 36 weeks RTT 0 3,275 1,794 Improved 1,647 1,374 1,105 762 372 0

Wait >8 weeks for diagnostic 0 192 48 Improved 27 0

Stroke unit within 4 hrs 59.7% 70.3% 71.1% Stable 81.1% 80%

Thrombolysed within 45 mins 12 month improvement

40.0% 60.0% Stable 40.0% 50%

Stroke CT scan within 1 hrs 54.4% 66.2% 78.0% Stable 83.7% 75%

Stroke consultant < 24 hrs 84.0% 96.0% 98.3% Stable 93.9% 95%

Urgent suspected cancer 95% 92.6% 90.7% Stable >90% est 93%

Non-urgent suspected cancer 98% 98.1% 97.2% Stable >93% est 98%

Red calls within 8 mins 65% 70.6% 66.1% Stable

65%

1 hour handover 0 141 200 Deteriorated 185 96 114 190 182 109

A&E 4 hour waits 95% 87.0% 83.4% Deteriorated 84.0% 86.3% 85.2% 84.0% 83.6% 86.8%

A&E 12 hour waits 0 389 663 Deteriorated 737 402 376 528 485 387

Mental health DTOC (R12m) <=10% reduction to 17/18 EOY position

134 86 Improved 93 5 per month

Non-mental health DTOC (R12m)

<=5% reduction to 17/18 EOY position

259 491 Deteriorated 485 34 per month

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National Target

Position at Sep 2017

Position at Sep 2018

Sep ‘18 compared to Sep ’17

Position at Oct 2018

2018/19 Trajectories

Nov ’18

Dec ‘18

Jan ‘19

Feb ‘19

Mar ‘19

Population reduction rate E.coli Rate<=67 Average

n:<22 122.15 96.16 Improved 95.12 <36 per month

Population reduction rate C.difficile

Rate:<=26 Average n: <9

43.14 46.26 Stable 42.23 < 10 per month

Population reduction rate S.aureus

Rate<=20 Average n:<7

33.27 32.23 Stable 33.78 < 10 per month

Local Primary Mental Health <28 Days Assessment

80% 77.8% 87.5% Improved NA 80%

Secondary mental health care and treatment plan (CTP)

90% 91.9% 91.2% Stable NA 90%

% of full time equivalent days lost to sickness absence (r12m)

Reduction 5.07%

(Aug 17) 5.04%

(Aug 18) Stable

5.02% (Sep 18)

4.98 4.97 4.95 4.93 4.92

% staff undertaking PADR >= 85% 63.3% 70% Improved 73% 73.5% 74% 74.5% 75% 75.5%

Staff compliance with Core Skill Training Framework (CSTF)

>=85% 58.5% 73.3% Improved 73.4% 74.7% 76.1% 77.4% 78.7% 80%

Hospital initiated cancellations within 24 hours of procedure for non-clinical reasons

5% improvement from 2017/18

104 168 Deteriorated NA Closely monitor during the winter months

against a target threshold of 115

Delayed Follow Ups (All Specialties)

Reduction 28,587 33,981 Deteriorated 34,410 33,528 32,646 31,764 30,882 30,000

Delayed Follow Ups (5 planned care specialties)

Reduction Not

available 16,605 N/A 16,887 16,410 15,993 15,456 14,979 14,502

Number of patients waiting more than 14 weeks for a specific therapy

0 2,554 352 Improved 332 312 226 123 69 0

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Annex 2: 2018/19 Annual Plan Action Plan position

Carmarthenshire County Plan

1. Extend Social Prescription model across all three Localities:

2. Support communities to become Dementia Friends. Target 2 communities per Locality

3. Evaluate current provision for participation in physical activity in the community with leisure colleagues

4. Increase public use of Independent Living Centre for the provision of information and advice re independent living and equipment (including Technology Enabled Care)

5. Develop / Identify ‘carer’ training opportunities

Ceredigion County Plan

1. Number of user led organisations, CICs and social enterprises supported per county

2. Number of additional entries onto Dewis and Info Engine quarter per county

3. Number of hits on Dewis website

4. Number of people participating in self-care programs

5. Number of people supported by an Intermediate Care Pathway / rapid access services

6. Number of stay well plans enacted

Pembrokeshire County Plan

1. Compassionate, resourceful and resilient Communities

2. Integrated Localities and Community Networks

3. Joint commissioning/ pooled budgets

4. Responsive Clinical Services

5. Palliative Care Plan

Primary Care

1. GMS Hub Model: We will develop an integrated and collaborative networked model of primary care which will enable whole areas to be more sustainable, develop wider workforce skill mix and deliver population based services.

2. Integration: We will work together, demonstrating shared responsibility, with our population families and communities to ensure we all enjoy optimal health, wellbeing and a sustainable and resilient future.

And 3. Locality Development: We will have seven active, enthusiastic and proactive

Localities, empowered to develop new service models based on their local population need and the Health Board will learn from these and implement as appropriate.

4. GMS Core Service: We will commission accessible safe and sustainable GP services for our population with a focus on continuous learning and building on existing strengths.

5. Managed Practices and Sustainability: We will support managed practices to be sustainable and link with neighbouring independent contractors to focus on the broader sustainability of the whole area.

6. Community Pharmacy: We will develop clinical community pharmacy services to support preventative care within our communities promoting wellness, self-care and ease of access.

7. General Dental Services: We will develop our dental capacity to meet the need for

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our population for preventative routine and emergency care and treatment.

8. Community Dental Services & Design 2 Smile

9. Community Optometric Services

Therapies

1. Making sure that the right staff are in the right place: Review of current staffing mapped against areas of need and known gaps in service provision, and development of options for workforce re-design/re-alignment/investment for sustainable service delivery

2. Making sure that the right staff are in the right place: Review of therapies and health sciences in key clinical pathways and areas of service re-design e.g. unscheduled care, admission avoidance, inpatient flow and discharge and planned care

3. Making sure that the right staff are in the right place: Further develop therapy and health science roles in primary and community care, whilst balancing demands in secondary care

4. Therapists and Health Scientists doing only what they can do: Qualified therapists and health scientists working at the top of their licence, with further development of support worker roles supported by robust governance structure

5. Stronger senior leadership: Establish a single operational lead for therapies i.e. Clinical Director.

6. Stronger senior leadership: Adopt a structured shared approach to representation across Therapies & Health Sciences to strengthen engagement in both operational and strategic planning.

Radiology

1. Continue with recruitment campaigns in collaboration our Workforce and Organisational Development Directorate to fill recruitment gaps within Radiology

2. Respond to outcomes from submitted capital bids to Welsh Government for a 2nd CT scanner and an enhanced Fluoroscopy room in Glangwili

3. During 2018/19 implementation of a single RadIS account across the four main hospital sites, to support continuity of care for patients visiting more than one site.

Governance

1. Design and Delivery of a Board Development Programme with Executive Directors and Independent Members together to ensure the Board has the right skills to discharge their duties in relation to the development and delivery and the IMTP.

2. Further develop the corporate risk register to ensure the Board are clear where operational risks could impact the delivery of the Health Board’s strategic objectives

3. Redefine the Board’s risk appetite statement and tolerances to align with strategic priorities following review of strategic objectives

4. Further develop the Board Assurance Framework to improve links to risks, performance and assurance to ensure the Board is regularly provided with statement of confidence of the likely achievement of the strategic objectives

5. Further improve the monitoring of the delivery of recommendations from regulatory and audit reviews and inspections to help prevent delays in implementation in accordance with agreed timescales to improve the level of assurance provided to Board

Digital Plan

1. Managing a single, digital view of a patient’s care and history across

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Primary, Community and Secondary services, improving patient centric care, reducing delays in information seeking and removing re-keying errors

o Phase 1 - Patient / Citizen Portal o Welsh Community Care Information Solution (WCCIS) for Ceredigion Community

Staff o Medical Transcribing and eDischarge (MTeD) – within the current resources

available o Further developments of the Welsh Clinical Portal (WCP) o E-observations

2. Providing the digital tools to support employees in their day to day activity, reducing admin and travel time and enabling increased clinical contact

o Rollout of Skype for Business, o Single sign on, o IT Self-Service web portal o Improvements in Telecare / Telemedicine

3. Digitising the processes across the Health Board that support patients and employees across all care settings

o Welsh Hospital Electronic Prescribing and Medicines Administration, (WHEPMA) o Welsh Clinical Portal (WCP) extensions, o Further roll out of PROMs / PREMs

4. Digitising the processes across the Health Board that support patients and employees across all care settings, removing manual effort, eliminating paper and capturing valuable, reusable data as standard

o Mobile Device Management Strategy, o Rollout of Skype for Business, o Employee Self-Service - Kiosks and apps, o Bed management and Handover system, o Edocumentation o Paperless organisation o Digital dictation o Electronic requesting for all diagnostic services o RADIS merger

5. Putting in place the enabling infrastructure and maturing the key supporting capabilities needed to deliver the strategy

o Data centre consolidation, o Cyber security enhancements, o Infrastructure refresh, o Switchboard rationalisation

Capital

1. Cross Hands Integrated Care Centre

2. Cardigan Integrated Care Centre

3. Aberaeron Integrated Care Centre

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4. Wards 9 and 10 - Withybush

5. Women and Children’s Phase 2 - Glangwili

Workforce and Organisational Development

1. Turnaround recruitment – actions being undertaken

2. Turnaround recruitment – link to reduction in vacancies

3. Turnaround variable pay – nursing and health care support worker

4. Turnaround variable pay - medical

5. Transformation – workforce development

6. Transformation – organisational development

7. NHS Outcomes Framework – sickness absence

8. NHS Outcomes Framework – mandatory training

9. NHS Outcomes Framework – PADR compliance

Service Improvement

1. Reduce DNAs/CNAs across each specialty to reach agreed target

2. Clinical templates reviewed and agreed to fully utilise capacity

3. Record the outcome of each patient contact or decision

4. Ortho-geriatric hip fracture pilot

5. A cross service single elective surgery pre-assessment pathway with centralised data capture

• Analysis of current capacity and demand across all sites.

• Map current pathways.

• Review all current documentation and forms used across all sites.

• Use the outcomes of the above milestones to inform a single elective surgery pre-assessment pathway a) pre-screening.

• Use the outcomes of the above milestones to inform a single elective surgery pre-assessment pathway b) pre-assessment

Research and Development

1. Increase the number of Chief Investigators (HDUHB-led research studies) and Principal Investigators (hosted studies)

2. Increase the number of research studies which are registered on the Health and Care Research Wales Clinical Research Portfolio, and increasing the number of subjects recruited into Portfolio studies through development of new studies and funding applications.

3. Increase the number of commercially sponsored studies, increasing the number of patients recruited into such studies

4. Increase Primary Care Research through promotion of Primary Care Research Incentive Scheme (Health & Care Research Wales) and increased support to Primary Care. Look to develop HDUHB led primary care studies.

5. Establish Research Governance audits

Clinical Audit

1. 29/35 of National Projects are green

2. 4/35 of National Projects are amber:

• Major Trauma Audit (TARN) – variable compliance across 3 sites

• National Ophthalmology Audit – no compliance at 4 sites but planned

• National Heart Failure – variable compliance across 4 sites and future compliance

• Myocardial Ischaemia National Audit Project (MINAP) – variable compliance across 4 sites

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3. 2/35 of National Projects are red:

• Inflammatory Bowel Disease – only 1 of 4 sites participating

• Fracture Liaison Service Database – no compliance at 1 applicable site

Cancer

1. Work towards implementation of the Single Cancer Pathway during 2018/19 so that the investigation (and treatment) of all patients for whom a suspicion of cancer is identified should be monitored from the point cancer is first suspected and not, as is the case with the Non-Urgent Suspected Cancer (NUSC) pathway, from the date of a decision to treat.

2. We will continue our improved approach to managing our cancer performance including an increasing focus on clinician engagement, clinical outcomes and strengthening links with tertiary centres, the South West Wales Cancer Centre (SWWCC) and Wales Cancer Network (WCN).

3. Continue a programme of improvement across all cancer pathways to support the initial assessment of patients within 10 days of receipt of referral, prioritise diagnostic pathways and continue to work with our tertiary centres to find solutions to capacity pressures for specialist services not currently available locally in HDUHB.

4. Further increases in local Chemotherapy delivery across the University Health Board as a consequence of joint service planning with ABM University Health Board, reducing the need for patients to travel outside of the University Health Board area for treatment.

Mental Health and Learning Disabilities

1. Adult Mental Health - IAS service to have fully recruited and to be operational

2. S-CAMHS - Expand neurodevelopmental service in collaboration with child health

3. Learning Disabilities - Repatriation of Clients: Review of Market Position and development of relationships with Private Care Providers, to facilitate commissioning of placements which are ‘Closer to Home’

4. CDAT - Continuing to develop the Specialist GP roles as level 3 doctors as part of the main stream service, and consider succession planning.

5. Commissioning - Identify resources to undertake review of all placements to establish current and future needs and realign packages and costs to reflect actual needs

Pharmacy and Medicines Management

1. Work with the wider service to identify opportunities where pharmacists can support a multi-disciplinary approach at front of house areas such as Accident and Emergency departments, clinical decision units. This will improve patient flow, reduce medicine related harm and improve the electronic transfer of medicines information between the sectors.

2. Continue to support GP practices working a part of the practice teams and further develop these roles, influencing repeat prescribing, polypharmacy reviews and providing support for patients with concerns relating to medicines.

3. Continue to support and develop the implementation and uptake of new medicines such as the new treatment fund and uptake of patient access schemes and homecare cross Hywel Dda to improve patient care and efficiencies

4. Continue to support the development of an integrated Pre-Registration year, rotational posts across sectors and increase the numbers of independent prescribers to support patient care across all sectors.

5. Work with estates and planning to develop a fully costs plan for the replacement of

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the aseptic unit in GGH to provide a modern and safe aseptic service provision for the delivery of safe manipulation of high risk medicines to our patients.

Planned Care

1. Ophthalmology: Deliver Glaucoma screening / monitoring clinics delivered by Optometry Service

2. Ophthalmology: Implement community based Ophthalmic Diagnostic & Treatment Centres to support direct listing of cataract referrals for surgery and thereby reduce demand on Stage 1 capacity

3. Ophthalmology: Implement NHS Wales PCB Eye Care Outcome Focused Measures which signal a reprioritisation of clinical capacity from traditional new and follow up patients to a revised categorisation of patients based on their assessed clinical priority (irrespective of new referral or follow-up status).

4. Dermatology: Appointment of new consultant Dermatologist

Stroke

1. Progress collaborative work with ARCH and WAST to develop a hyper acute stroke care model to include engagement with Powys and BCUHB. This model will include the use of technology and innovation to address rural challenges and will require significant investment across the complete stroke care pathway.

2. Finalise interim commissioning and service agreement with thrombectomy service providers in England.

3. Improve access to neurovascular clinics across the UHB to provide 5 day a week service with timely access to imaging, working towards a 7 day service linked with the development of a hyper acute stroke care model.

4. Initiate a clinically led multi professional group to review IHB community stroke rehabilitation services and develop a future model that will provide earlier discharge opportunities for eligible stroke patients with stroke specialist rehabilitation. This work is integral to the development of the hyper acute stroke model.

Unscheduled Care

1. Development and implementation of consistent front door assessment model, to include; streaming; redirection; pit Stop’ triage; develop further alternative pathways to avoid admission to hospital, and; implementation of ambulatory emergency care strategy and standards

2. Fully embed SAFER patient bundle to improve senior review before midday; to develop and implement clear consistent process for estimated date of discharge & clinical criteria for discharge; to improve discharge before noon (33% target), and; to reduce % of stranded patients (those with LOS > 7 days)

3. Implement discharge to assess pathways

Women and Children’s

1. Continue our efforts to recruit to all current consultant & middle grade (SAS) vacancies

2. Work to strengthen paediatric & neonatal nurse staffing to reduce our reliance on agency nurses

3. Progress plans to strengthen neonatal experience amongst our consultant and middle grade medical staff via operational experience at the tertiary Neonatal unit

4. All patients receive their elective treatment within 36 weeks of referral

5. Increase the proportion of patients waiting 26 weeks or less for treatment Nurse Staffing Levels

1. Review and recalculate the nurse staffing levels for the 30 ‘included’ wards in early autumn 2018, in line with the timetable within the Operational Handbook (which will

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be issued by WG in march 2018) and to reflect the requirement of the statutory guidance to undertake this nurse staffing level calculation every 6 months

2. Review the staffing of all other clinical nursing teams across the University Health Board using the triangulated approach to the extent that is possible (i.e. as most other services do not have the benefit of evidence-based workforce planning tools)

3. Work collaboratively with colleagues across Wales to fully understand and respond to the implications of the Act with respect to commissioned services

4. Implement an internal, structured communication/ training strategy to ensure staff of all disciplines are briefed about the Act, trained and able to achieve the requirements of the Act as it impacts on them and their roles, and understand what the HDUHB are doing to ensure compliance with it;

5. Implement a strong communication and engagement structure about the implementation of the Act within the University Health Board with our external stakeholders (including Staff Partnership Forum and Community Health Council)

6. Develop the nursing workforce to ensure the nurse staffing levels can be achieved despite the recruitment challenges in relation to registered nurses anticipated over the next 2-3 years

7. As a University Health Board, continue to offer a strong presence and contribution to all specialty work streams within the All Wales Nurse Staffing programme

8. Formally report to the Board annually and also as required to ensure that the Board are fully appraised of the emerging issues associated with this Act and its implementation.

Quality and Safety – Patient Experience

1. Seek to invest in a new web-based experience evaluation tool;

2. Strengthening our Patient Advice and Liaison Services (PALS) at all hospital and community sites, including over weekends;

3. Implement a strengthened governance process to ensure learning from events is captured, actions are monitored to ensure improved patients outcomes and experiences of both patients and staff

Quality and Improvement Framework Implementation

1. Dissemination and communication of the framework

2. Collaborative Approach Implemented

3. Monitoring of Impact of Framework

Infection Protection and Control Improvement

1. Agree annual health promotion communication / campaign programme

2. Further reduction in CDI

3. Reduce prevalence of catheters and strengthen catheter care to reduce risk of catheter associated urinary tract infections

4. ‘How to guides’

Communication and Engagement

1. Tailor calendar to prioritise engagement and communications support for:

• Turnaround

• Transforming Clinical Services

• Transforming Mental Health Services

2. Supporting the Stakeholder Reference Group to meet its key purpose and play an active role in supporting engagement activity across the university health board

3. More effective use of Siarad Iechyd / Talking Health as an engagement tool

4. Communications team to prioritise and deliver the three key communication campaigns to support all of the above, in areas which will have the biggest impact in

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supporting the organisation to achieve its annual plan. These will fit alongside other directorate campaigns as listed below.

• Proposed campaigns:

• Recruitment and retention

• Engaging and communicating service change (transformation work)

• Choose Well (to include all aspects of improving public awareness on how to navigate the local healthcare system, including seasonal messages)

• Keeping ourselves well (public health campaigns and self-care support e.g. #red2green #pjparalysis)

5. Deliver key corporate publications – to include Annual Report, Annual Quality Statement and other overarching corporate documents in tandem with leads from other directorates (timetable tbc depending on regulatory authorities)

Welsh Language

1. Provide a comprehensive translation service for the whole of the organisation

2. Learn Welsh – provide/ facilitate a broad programme of learning Welsh Language

courses for all groups of staff across UHB

3. Promote the use of Welsh Language within Primary Care settings

Carers

1. Continue to consolidate the roll-out of the current IiC programme during 2018/2019 and increase the number of settings achieving an IiC award.

2. Review all services commissioned for Carers across the Region and identify synergies and economies across Health & Social Care.

3. Audit Carers Assessments to review effectiveness in order to identify actions to improve front line service delivery, particularly discharge from hospital and transfer of care that support WG and Regional priorities.

4. Review workforce policies across the Region identify and share best practices that enhance recruitment, retention and development of the workforce with Carer responsibilities.

Public Health Wales Act (the UHBs contribution to meeting the Act)

1. Smoking

2. Obesity

3. Pharmaceutical needs assessment

4. Licences on ‘special procedures’

5. Toilet facilities

6. Health Impact Assessment