1 · web viewsl gave a presentation to members, representing the 60 day report out. the rpiw had...

Staff Governance Committee23 August 2016

Item 3

STAFF GOVERNANCE COMMITTEEReport by Anne Gent, Director of Human Resources

The Board is asked to:

Note that the Staff Governance Committee met on Tuesday 17 May 2016 with attendance as noted below.

Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present:

Alasdair Lawton, Board Non-Executive DirectorDavid Alston, NHS Board Chair Robin Creelman, Board Non-Executive Director (Videoconference from 10.05am)Myra Duncan, Board Non-Executive Director Anne Gent, Director of Human Resources – In the ChairAdam Palmer, Employee Director

In Attendance:

Gaye Boyd, Deputy Director of Human ResourcesPam Cremin, Workforce Planning and Development ManagerStephen Loch, Senior Nurse for Education and Training (from 10.15am)Paul Maber, Learning and Development Business Support Manager Margaret MacRae, Staffside RepresentativeJudith McKelvie, Head of Learning and DevelopmentBrian Mitchell, Board Committee AdministratorMr Paul Simmons, Learning and Development FacilitatorRay Stewart, Quality Improvement Lead for Staff Experience

Apologies:

Etta Mackay, Staffside RepresentativeElaine Wilkinson, Board Non-Executive Director

AGENDA ITEMS

Statutory and Mandatory Training RPIW – Tier One Report Out IHI Joy at Work Presentation Staff Experience and iMatter Activity Update Staff Governance Monitoring Framework Return 2015/16 NHSH Workforce Risk Register Workforce Contribution to Local Delivery Plan Workforce Report Review of Agenda for Change Band 1 Posts – Scottish Terms and Conditions

Committee Discussions Fixed term Contracts Update on Paid as if at Work Knowledge and Skills Framework (including National Developments) Update Staff Governance Committee Annual Report 2015/16

DATE OF NEXT MEETING

The next meeting will be held on Tuesday 23 August 2016 in the Board Room, Assynt House, Inverness at 10.00am.

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STAFF GOVERNANCE COMMITTEE – ASSURANCE REPORTMeeting on Tuesday 17 May 2016

1 TOPIC: Welcome and Declarations of Interest Issues Assurance ActionsDo members have any interest to declare in relation to any Item on the agenda?

No declarations made. Action:

2 TOPIC: Draft Assurance Report and Action Plan – 25 August 2015 Issues Assurance ActionsAny issues relating to accuracy of draft Assurance Report?

Need to update Action Plan

On the matter of scrutiny/assurance taken by the Committee it was agreed this be explicitly outlined in future Assurance Reports.

Agreed.

Action: Agreed level of assurance taken to be made explicit

in future Assurance Reports – Committee Administrator

Action Plan to continue to be updated – Named Officers/ Committee Administrator

3.1 TOPIC: Matters Arising – Role of Non Executive Whistle Blowing Champion Issues Assurance ActionsWhat discussion has taken place in relation to this role?

AG advised she had met Mr Creelman, with G Boyd and A Palmer, to discuss the role of Whistle Blowing Champion. Relevant Guidance for the role would be included within the NHSH Whistle Blowing Policy.

Action:

The Committee agreed to consider the following Items at this point in the meeting.

4.1 TOPIC: Minutes of Meetings of the Highland Partnership Forum on 12 February and 11 March 2016 Issues Assurance ActionsAny Issues arising from the Minutes?

AP advised there had been a Workshop Event in relation to reinvigorating the Partnership Forum, recommendations from which were to be considered

Action:

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What emerged from discussion in relation to Smarter Offices proposal?

What activity is underway in relation to improving recruitment processes?

at the meeting to be held on 20 May 2016. Issues being considered included attendance and commitment of members, meeting arrangements and a re-structured agenda, member roles and responsibilities, review of Constitution, support for Local Partnership Fora and information sharing.

AP advised there was a level of concern being expressed by affected staff. Workshop events would be held across all three sites involved to highlight is about making best use of available office space. Noted working from home raised number of eHealth issues and that there may need to be a degree of building work/improvements at Assynt House. Dr van Woerden to Chair the relevant Project Board.

PC advised currently undertaking RPIW on recruitment processes, with specific Corporate Objectives developed for 2016/17. NHSH operated a positive youth employment agenda, and talent development and succession planning issues were being developed with Sensei support from Virginia Mason Institute (VMI). The next iteration of the NHSH Workforce Plan would include greater reference to this subject and would be submitted to the NHS Board in August 2016 for approval and sign-off.

4.2 TOPIC: Minute of Meeting of Health and Safety Committee on 5 November 2015 Issues Assurance ActionsAny Issues arising from the draft Minute?

AG advised there had been discussion in relation to the range of Health & Safety Training activity.

Action:

The Committee agreed to revert to the original agenda at this point in the meeting.

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5 TOPIC: Statutory and Mandatory Training RPIW – Tier One Report Out Issues Assurance ActionsWhat has been the focus of the recent RPIW activity on Statutory and Mandatory Training?

AG introduced the Item, advising this had been raised as an organisation wide issue by the Audit Committee. The report considered by the Audit Committee at their meeting on 10 May 2016 was circulated for information. SL gave a presentation to members, representing the 60 Day Report Out. The RPIW had focussed on Band 5 nurses in general wards and their key training programmes relating to Fire, Resuscitation, Moving & Handling, Violence & Aggression and Plated Food handling. The RPIW theme was to develop a robust system for staff to identify and undertake appropriate statutory and mandatory training; reduce waste, improve lead time and access to appropriate training; and to reduce waste and improve recording so that the individual and the organisation can ensure staff are appropriately trained within a specified period. The RPIW had subsequently been widened to include Band 2 staff in general acute wards. SL introduced the relevant target progress report and value stream map, advising the process had identified 23 wastes and generated 36 ideas. It was reported that at the end of day 4, in simulation, improvements had been identified including a reduction in lead time from interview to training completion, and a reduction in training cancellation and Did Not Attend rates. JMcK circulated the relevant RPIW/Kaizen newspaper and introduced activity after the 30 day report out, advising a number of actions involved a lead in time. Areas of focus were outlined as being in relation to recruitment; scheduling, booking and recording of training, induction process, overall governance and communications. The new induction programme

Action:

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Why introduce a paper training passport as opposed to an IT solution and how do staff members identify their Statutory and Mandatory training needs?

commenced on 9 May 2016. JMcK advised the 60 Day Report Out reflected the lead in time for many of the actions. An overview was given in relation to the new induction process, including an outline of relevant responsibilities for training providers and their admin support. JMcK emphasised this was about ensuring a person centred approach for new starts in NHSH. Reflecting on the start point of the RPIW, and the areas identified for consideration, JMCK took members through improvements to date, and ongoing actions, including identification and provision of actual individual staff training requirements, development of standard work, development of a training passport for staff and ensuring IT access for new staff to complete relevant training. Moving forward, the challenges were indicated as being in relation to capacity to manage the induction process for new staff, admin support, management of the training passport and the ability to match capacity to demand.

During discussion, and on the points raised, it was advised the relevant sample number provided those involved with a valid test cohort. The two week induction period for completion of training would be considered a maximum timeframe and would depend on individual staff member needs. It was confirmed that aspects relating to revalidation would be included within the training passport. JMcK advised, in light of current issues relating to introduction of future IT solutions this represented a practical way to test new processes whilst introducing a degree of staff member personal responsibility. She advised training needs were identified in the Training Prospectus available via the NHSH Intranet site.

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How can learning be applied across NHS Highland?

When will reporting be available to provide appropriate levels of assurance?

Key areas for action were outlined to members including managing the increasing level of Statutory and Mandatory training required and considering how best that can be delivered efficiently. There was need for identification of role requirements to in turn inform post outlines, PDP discussions, updating of the prospectus and development of educational frameworks, especially for non-clinical staff. There was need to further consider how training was accessed and booked, ensuring capacity to attend and matching training capacity to demand. PM gave an example of data being utilised and emphasised the importance of ensuring consistent information and processes. Aspects relating to access to training records, including the proposed training passport, were being considered alongside the possible introduction of a Dashboard approach and scoping of the impact of the new NES system being introduced. In terms of governance reporting consideration was also being given to the Learning Plan, Committee level reporting, Data Collection Plan, relevant educational governance aspects and working with RPIW teams to develop compliance reporting arrangements. PM concluded by outlining the range of people/groups within NHSH with responsibilities in relation to Statutory and Mandatory Training and outlined the relevant next steps to be taken.

JMCK stated the importance of being able to ensure that data being collected was accurate, as a starting point for reporting. AG emphasised the governance role of this Committee and the need to be able to provide Operational Units with accurate data. She also emphasised the role of Professional Leads and the need for an appropriate Communications Plan to

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be developed. DA stated it was important to establish effective processes to ensure that NHSH was able to confidently produce accurate compliance information and AG advised that establishing this for relevant priority areas was the initial focus at this time. The Committee thanked those presenting for such a comprehensive update.

S Loch and P Maber left the meeting at 11.35am.

6.1 Highland Quality Approach – IHI Joy in Work Presentation Issues Assurance ActionsHow can NHSH ensure a positive working experience for staff?

AG gave a presentation to members, previously delivered at an IHI Conference in December 2015, on ‘Creating Joy in Work’. Noting more work days are lost in healthcare than in traditional heavy industry the back to basics message was to establish why staff entered their profession and determine what makes them joyful at their work. Both the individual and organisation should seek to influence this aspect as it was stated “without joy and meaning, the workforce cannot perform to its potential” and this resulted in lower quality of care, diminished patient satisfaction and increased medical errors. The day to day experience of staff was examined in terms of how a positive inner work life led to higher performance. Joy in work was influenced in turn by developing helping relationships in the work place and establishing a culture of co-creation. It was stated, in delivery of a service, any disconnect between individual and organisation creates a challenge to person-centred care while a loss of purpose for providers in turn depletes Joy at Work. In summary the presentation had emphasised healthcare is a calling that provides

Action:

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meaning and joy in work, although burnout amongst providers is high. It was stated research, strategies and action need to be taken to address this issue. The main aim was to ensure every day was “your best day in healthcare”. The Committee thanked Mrs Gent for sharing the presentation content with members.

6.2 TOPIC: Staff Experience and iMatter Activity Update Issues Assurance ActionsWhat is the current position in relation to iMatter within NHS Highland?

Mr Stewart advised that Cohort 1 was in the process of participating in their first anniversary cycle, with the associated response rate having risen to the 60% level required for production of a Board report. The production of Action Plans remained an issue of concern in relation to Cohort 1. There had been little improvement in relation to the production of Action Plans for Cohort 2 despite additional focus and discussion. It was reported Cohort 3 had achieved a positive 69% response rate which would in turn result in production of an updated Board report. Initiation of activity in relation to Cohort 4 (South and Mid Division) had been delayed until after Summer 2016, as agreed with the National Programme Lead and with a view to achieving a higher response rate with the main summer holiday period having passed. Cohort 5 had also been deferred slightly although Argyll and Bute activity would proceed as previously outlined. All required activity will be complete by the end 2017 deadline. Mr Stewart again emphasised the importance of teams developing their respective Action Plans and stated visible leadership from the NHS Board and Executive Team was important.

Action: Report Noted.

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During discussion, concern was expressed that the increasing demands placed on staff at this time were impacting on performance in a range of Staff Governance areas including iMatter, Staff Survey, KSF/PDP, and training activity. RS emphasised that response rates were positive however Action Plan production was not as yet following the same trend, risking staff disengagement. Mrs Gent emphasised the role of individual staff members in taking matters forward, and stated that recognising that day to day quality improvement activity also represented HQA/iMatter activity then making the relevant connections would be easier for front line staff. She also emphasised the wider role for Staffside representatives in encouraging greater iMatter engagement. PC stated that by linking the wider workforce agenda to such activity, and by providing a daily focus on matters relating to engaging, providing leadership and enabling staff, relevant activity would likely be increased. AG confirmed the HPF were to further consider the idea of introducing HQA Team Boards.

The Committee adjourned at 12.10pm and reconvened at 12.15pm.

7.1 TOPIC: Staff Governance Standard Monitoring Framework 2015/16 Issues Assurance ActionsWhat is the position in relation to the Staff Governance Standard Monitoring Framework Return 2015/16?

How does NHSH Promote and

AP spoke to the circulated Monitoring Framework 2015/16 Return, this having been completed with submissions from Operational Units. The Return was to be signed off and submitted to the Scottish Government in line with relevant requirements.

On the point raised by M Duncan it was agreed that

Action:

Agreed to the inclusion of reference to Staffside

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embed partnership working? reference be included within Section 3.1 to the inclusion of two Staffside representatives as members of the Highland Health and Social Care Committee.

membership of HHSCC prior to Return submission – A Palmer/G Boyd

8.1 TOPIC: NHS Highland Workforce Risk Register Issues Assurance ActionsWhat is the position in relation to developing the Human Resources Risk Register?

PC spoke to the circulated updated Human Resources Risk Register, which was to be submitted to the Risk Management Steering Group (RMSG). Elements relating to Corporate Annual Objectives would be included once approved by the NHS Board. She advised that the RMSG had sought inclusion of an element relating to the increasing use of locum staff. The element relating to Statutory and Mandatory Training also appeared on the Health & Safety Risk Register. The Register was reviewed as part of the Workforce Development Plan Rolling Action Plan.

Action:

8.2 TOPIC: Workforce Contribution to Local Delivery Plan Issues Assurance ActionsWhat is included within the Workforce Section of the NHSH Local Delivery Plan 2016/17?

PC spoke to the circulated Workforce Narrative relating to the NHSH Local Delivery Plan 2016/17, based on the NHSH Everyone Matters: 2020 Workforce Vision implementation Plan 2016/17. She drew the attention of members to the section on Workforce Development and highlighted the issue of affordability. Mrs MacRae stated the circulated document represented an opportunity to highlight the ability to influence partner agencies as part of Social Care integration, such as in relation to pay levels for

Action:

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staff not employed by NHS Highland.

9.1 TOPIC: Workforce Report Issues Assurance ActionsWhat are the issues highlighted through Workforce data at this time?

How should future data requirements be reported to Committee?

How are Capability Cases being affected by the wait for a revised PIN Policy?

GB introduced the circulated narrative and Workforce Report, as at end March 2016 and highlighted matters relating to agency use, recording of reasons for the use of fixed term contracts and an upward trend in relation to both national and local sickness absence rates. GB also highlighted that a revised National Promoting Attendance PIN Policy was awaited and this was having an effect on how cases relating to Capability were managed and reported at this time.

The circulated report also included a series of suggestions in relation to future reporting arrangements for Workforce Information and members were invited to consider these as part of discussion. Suggestions included development of an annual report, with specific Committee updates through the year, review of reports provided to Operational Units, a revised data set for the Appropriately Trained elements, omission of certain data and provision of further breakdown of data for some areas. Members suggested that comparator and trend data would also be beneficial.

It was advised relevant cases were being actively monitored and managed through an internal process. Waiting for the revised National Promoting Attendance PIN Policy resulted in a number of attendance related issues being managed through the Capability process, as previously agreed by the HPF.

Action:

Agreed further consideration be given to future reporting arrangements – G Boyd

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How does NHSH plan for managing an ageing workforce?

Why is some Equality and Diversity data listed as unknown?

AG advised the implications of an ageing workforce were considered in the Occupational Health Annual Report 2015/16 and agreed to circulate the same. MD advised that concerns had also been raised at District Partnership level.

On the point raised GB undertook to look in to this point and report back.

Agreed to circulate Occupational Health Annual report to members – B Mitchell

Agreed to establish reasons for data listed as Unknown – G Boyd

9.2 TOPIC: Review of Agenda for Change Band 1 Posts – Scottish Terms and Conditions Committee Discussions Issues Assurance ActionsWhat is the position in relation to review of Band 1 posts in NHSH?

AP spoke to the circulated correspondence in relation to the review of the roles and responsibilities of staff on Agenda for Change Pay Band 1 and advised a project team had been established to take this matter forward in NHSH. The effective date for the review was 1 October 2016 and later activity would be backdated to that date if required. AP advised that the process would include the discussion and offer of Band 2 posts to individual staff members although it was recognised that a number may not wish to take up this opportunity. Overall, relevant changes may afford an opportunity for consideration of service redesign aspects. Associated financial implications had been factored in to future budgets. Relevant communications activity had commenced and the project would be overseen by the Highland Partnership Forum.

Action:

Agreed regular updates on activity be brought to this Committee – A Palmer/G Boyd

9.3 TOPIC: Fixed Term Contracts

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Issues Assurance ActionsHow are fixed term contracts used and monitored in NHSH?

GB spoke to the circulated report and advised the NHSH Use of Fixed Terms Contracts (FTCs) Policy was currently under review. NHSH was expected to review the use of FTCs to demonstrate these were used only where appropriate and necessary. All staff on fixed term contracts should have their position reviewed mid-term and thereafter as appropriate, with the three options available being making the post permanent, extending the length of the contract or giving notice that the term of the contract was to come to an end. At the time of the report there were 515 fixed term contracts recorded although reasons for these were not always provided. The circulated report included a number of associated proposed actions relating to Policy awareness, post approval, activity for existing and new contracts, workforce planning and relevant Committee monitoring and review arrangements.

Action:

Agreed a further report be submitted to the November 2016 meeting – G Boyd

9.4 TOPIC: Update on Paid as if at Work Issues Assurance ActionsWhat is the position in relation to Paid as if at Work activity?

AP advised an appropriate review had been included within the NHS Highland Internal Audit Plan 2016/17.

Action:

10.1 TOPIC: Knowledge and Skills Framework Update – Paul Simmons, Learning and Development FacilitatorIssues Assurance Actions

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What is the current position in relation to KSF?

Will revalidation activity improve the KSF position in Highland?

Where are the identified areas for improvement?

PS spoke to the circulated report outlining progress against trajectory, advising approximately 40% of staff (non-bank) had reviews completed signed off on eKSF in 2015/16. The downward trend evidenced in NHSH mirrored the national position, with contributory factors noted as including a lack of staff capacity and easy access to relevant training. PS advised that staff may be under the impression that KSF activity was to cease but it was important to emphasise the only change would be a future move from the eKSF to OPM recording system. Training, support and guidance were available to all managers and staff. With the introduction of OPM not yet confirmed the contract for eKSF had been extended to 31 March 2017, with the option for further extensions beyond that point. The Learning and Development Sub Group had agreed that a trial be undertaken within Raigmore Hospital using the revised KSF post outlines developed and agreed as part of the OPM project plan. Manager and staff reaction would be assessed to determine if wider use could then be adopted prior to full transition to OPM. Other supporting activity was also outlined and this included an updating of the KSF/PDP&R Quality Survey, and activity relating to both Adult Social Care and Children’s Services.

PS advised the crossover elements of both systems had been considered and it was hoped this would have a positive impact on activity levels. The circulated report included a summary of a number of KSF/PDP&R process elements identified for improvement by the Director of Human Resources along with a range of agreed supporting measures

Action:

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and actions.

11.1 TOPIC: Staff Governance Committee Annual Report 2015/16 Issues Assurance ActionsWhat has been included in the Committee Annual Report for 2015/16?

There had been circulated Staff Governance Committee Annual Report for 2015/16 which had been considered by the Audit Committee at their meeting held on 10 May 2016 as part of the Annual Accounts process. The Committee noted the report.

Action:

13 TOPIC: Any Other Competent Business Issues Assurance ActionsAre there any issues members wish to raise?

There were no issues raised in relation to this Item. Action:

14 DATE OF NEXT MEETING

The next meeting of the Committee will take place on Tuesday, 23 August 2016 in the Board Room, Assynt House, Inverness at 10.00am.

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1 · web viewsl gave a presentation to members, representing the 60 day report out. the rpiw had...

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