defining our values board report v1x - health in wales · unions across the health board....
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Betsi Cadwaladr University Health Board
Board Paper 23.6.11 Item 11/044.2
Subject: Engagement Programme – Defining our Values
Summary
or
Issues of Significance
This paper details the consultation that has taken place since February 2011 to involve the workforce and other stakeholders in creating a defined set of values and associated behaviours for Betsi Cadwaladr University Health Board. The report details the values which have been created by the staff and service-users and the actions required to embed the values and behaviours. The paper is accompanied by a Workforce Engagement Strategy which details how the Health Board will sustain the engagement programme.
National / Local Objectives Addressed:
The consultation and resulting values and behaviours have been underpinned by the 5 Strategic themes as detailed in the Health Board’s ‘A Strategic Direction:2009-12’.The work falls under the Health Board’s Organisational Development Strategy-Making it Happen.
Legislation or Healthcare Standard:
The Human Rights act principles known as FREDA
Healthcare Standards 1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 18, 19, 21, 22, 23, 25, 26,
Evidence base or other relevant information to inform decision(s)
Equality legislation, research into engagement, values and behaviours
Consultation
with others:
All staff groups have been represented; volunteer groups; service-users and carers. Consultation with Stakeholder reference Group, Partnership Forum, LNC, Healthcare Professionals Forum.
Consideration
of legal issues
Impact on
Other Services:
Delivery requires partnership working with staff, managers and Trade Unions across the Health Board.
Consequences
& Risks:
.
Consideration must be given to the impact of decisions on all groups of people. Public authorities must ensure decisions are made in such a way as to minimize unfairness and ensure that they do not have a disproportionately negative effect on people from different ethnic groups, disabled people, men and women.
Consideration must be given to the impact of decisi ons in respect of :
Age Race
Gender Sexuality
Disability Language
Religion and belief Human Rights
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=115&pid=21554
Has EqIA screening been undertaken?
Yes (attached)
Has a full EqIA been undertaken?
No
Equality Impact Assessment
(EqIA)
When developing proposals and making decisions, the organisation must comply with the statutory equality duties
Recommendations:
1. To agree the values and behaviours identified within the report and the actions required to embed them.
2. To support the actions identified in the Workforce Engagement Strategy.
Author(s) Mr Mark Sykes Assistant Director of OD/ Mrs Nia Thomas Head of OD.
Presented by Mr JM Jones, Executive Director of Workforce & OD
Date of report 10th June 2011
Date of meeting 23rd June 2011
BCUHB Coversheet v3.0
The Big Conversation – Defining our Values
1. Introduction
Shared and enduring values are at the heart of successful organisations. They provide purpose to all within the organisation and communicate expectations and service commitments to those who come into contact with the organisation. For the Health Board a strong set of values will provide the basis around which to coalesce the various strands of a sustainable engagement strategy driven by clinical leadership, openness and support for innovation and improvement.
We believe it is most helpful to see employee engagement as a workplace approach designed to ensure that employees are committed to the organisation’s goals and values, motivated to contribute to organisational success, and are able at the same time to enhance their own sense of wellbeing. Engaged organisations have strong and authentic values, with clear evidence of trust and fairness based on mutual respect, where two way promises and commitments – between employers and staff – are understood and fulfilled. (McLeod, D., Clarke, N., 2009. Engaging for Success: enhancing performance through employee engagement).
Leading organisations and leading brands share many common characteristics and arguably the most important of these is achieving consistency between internal behaviours and external messages in order to give them total credibility in the eyes of employees, service users and partners. In order to achieve this, staff need to be aware of, understand and be committed to the values of the organisation. This is not something that can be achieved overnight.
As defined in the Health Board’s Organisational Development Strategy, Lewin’s three stage model of culture change has been an important part of the process and methodology used to commence the work on defining the Health Board’s value statements. The proposed Workforce Engagement Strategy accompanying this report will be a key feature of the work required to embed the values.
2. Why do we need values?
There is a growing body of evidence to suggest that strong organisational values can lead to real, tangible improvement in performance. The benefits of strong local values are:
1. Improved patient experience 2. Improvements in patient safety 3. More staff satisfied with their jobs and workplace 4. Staff who identify more strongly with their organisation 5. Staff who feel more personally successful, and more supported in that
success by the organisation 6. Long term organisational success and impact
7. Increased public trust in professionals
(NHS Employers 2009)
The ultimate goal is for the values to be an integral part of everyone’s working life, no matter what their individual role. Value statements will also help us to define and develop our culture – what we do and how we do it. Publishing the values of the Health Board, making them part of our culture and demonstrating them throughout the organisation will help us to develop a shared way of behaving.
To support the highest quality of care at the front line, there is an organisational requirement for leaders to model the appropriate behaviours and to communicate these at every opportunity.
3. Methodology – how were the values formed?
Following an extensive period of consultation with clinical, non-clinical and managerial staff, service users and volunteers, the Health Board has identified a set of values and underpinning behaviours.
A variety of methods were utilised to engage with staff under the banner of the ‘Big Conversation’. Appealing to different engagement styles was important to us so we developed visual, pictorial and kinaesthetic materials. Events ranged from formal Big Conversation forums to world cafes and smaller drop-in sessions across community sites. The intranet was also utilised to engage staff through the use of a ‘chat’ forum to capture ideas and views. This forum had 2,631 hits in the period between 1st February and 25th May 2011.
In order to ensure the engagement activities involved service users and the public in addition to our staff, a questionnaire was designed for service users, carers, the general public and staff. 301 questionnaires were returned. All questionnaires were transcribed and themed/categorised. World cafes were also held for volunteers across the geographical area of the Health Board.
Throughout the period of engagement, presentations and interim progress reports have been provided to a range of committees and forums including the Partnership Forum; Local Negotiating Committee; Health Professions Forum; Stakeholder Reference Group and the Remuneration and Terms of Service Committee. Announcements and articles have also featured in the Corporate Notice board and Clebran/Talk about magazine.
Once the engagement events were completed a stakeholder group of key facilitators involved in a range of engagement activities participated in a workshop to shape the values and behaviour statements. All the values that had been categorised were circulated at the workshop and great care was taken to include the essence and language of all views represented in the values categories and behaviour statements. Two key guiding sets of principles were also followed during this workshop, the first were the Health Board’s 5 strategic themes; Making it safe; making it better; making it sound; making it work; and making it happen; the second were the FREDA principles which are Freedom; Respect; Equality; Diversity; and Autonomy.
Throughout the engagement events there has been a real ‘buzz’ from staff and a genuine interest and determination to create values that would be meaningful and could be easily related to in day to day practice.
A full range and details of the events with evidence of participation and engagement can be seen at Appendix 1.
An Equality Impact Assessment has been conducted on the work undertaken during the engagement events, this can be seen at Appendix 2.
4. What are the identified values and associated be haviours?
We can make it sound by putting patients at the heart of everything we do
• Take pride in the service we provide and display high ethical standards in order to improve standards of care
• Involve patients and their families in treatment decisions and outcomes • Demonstrate respect for privacy, choice, dignity and independence • Ensure each patient feels they have been listened to and treated as an
individual • Show empathy and be aware and sensitive to an individual’s needs
We can make it happen by working together for patients
• Work together positively to achieve efficiency, forward thinking and vision • Promote an environment of mutual support and cooperation among
individuals and teams • Embrace challenges, support each other and work together to overcome
problems • Develop a unified standard of excellence for performance and delivery of care • Always do what is right, even when challenged
We can make it work by learning and being innovative in all that we do
• Use our energy, enthusiasm and initiative to invest in our success • Encourage ownership and involvement in service improvement • Explore and challenge the boundaries of technology, clinical practice and
research • Encourage and support creativity to foster ideas for our future success and
demonstrate a ‘can do’ attitude • Maximise your own and others’ potential through learning, nurturing,
development and shared wisdom
We can make it safe by valuing and respecting each other
• Share, respect and celebrate our achievements together • Be approachable, visible, professional and inspirational as a role model for
others • Engage, listen and value the contribution of others • Appreciate the qualities and diversity of each individual and work together
towards a common purpose • Hold ourselves, individually and together, accountable for our decisions,
actions and performance
We can make it better by communicating openly and honestly
• Demonstrate honesty and integrity in our decision-making and communication • Build trust and display transparency in our actions as well as our words • Be professional, polite, courteous, and non-judgemental in our communication • Be honest, respectful and sincere in giving and receiving feedback
• Display accuracy, simplicity, respect and clarity in communications with our service users
5. What needs to happen now? � The Board is asked to agree/adopt the values and behaviours. � The values and behaviours will become a key part of everything that we do as
an organisation, being included in job descriptions and in our publications. � This will be reinforced through employee development (e.g. induction,
Personal Development Review) � The values and behaviours will be included in all leadership development
activities. � There needs to be a pictorial/logo representation to identify and communicate
the value statements, this will be submitted to the Board once the value statements have been approved.
� Following approval by the Board of both the value statement and associated logo it is proposed the values and associated behaviours will be disseminated utilising a small marketing strategy (to be approved by the Executive Director of Workforce &OD) to firstly raise awareness and then embed the values and behaviours into existing events such as recruitment activity, induction, leadership and management development programmes and the Health Board’s publications. This marketing strategy will also consider the longer term vision of how the values can be demonstrated and evidenced throughout the whole organisation and across all staff groups.
� There needs to be close liaison with the Governance & Communication Corporate Function to support the marketing strategy as it is crucial that staff can visibly see progress and development following the launch of the Value statements.
� As identified in the proposed Workforce Engagement Strategy, measurement of staff compliance with, and the success of the proposed behaviours can be measured through organisational culture and staff surveys, personal development reviews and development programmes. It is proposed to develop a team toolbox which will allow teams of staff to have discussions at team meetings regarding what the values mean to them in their roles and to their team and how they can demonstrate the behaviours which underpin the values and provide evidence of this behaviour.
� The Personal Development Review needs to be revised to incorporate objectives based around the 5 values.
� The Staff Achievement Awards needs to be reviewed to incorporate the 5 values.
6. Recommendations
6.1 The Board is asked to support the values and behaviour statement in section 4 of the report.
6.2 The Board is asked to approve the identified actions in section 5 of the report
The Big The Big The Big The Big ConversationConversationConversationConversation
Data Collection Final Report 10.06.11
Contents Page
The Big Conversation, what are we trying to do? Page 3
What have we done? Page 3
Panel Members and Facilitators Page 8
What questions did we ask? Page 9
Top Values Page 16
Focus Group Page 16
The Big Conversation, what are we trying to do?
We have started a conversation about what kind of organisation we want to be, what kind of values will define us as an organisation and which behaviours can underpin these values.
We are asking you to generate your ideas. Take your ideas back to your colleagues and have a conversation. What helps you give of your best for patients?
Engage everyone in shaping our Health Board to deliver the best service we can for patients, carers and the communities we serve.
What have we done?
Big Conversation Events
We held three Big Conversation Events on the 14th, 15th and 16th February 2011, in different locations. Overall there were a total of 187 participants.
Count of Participants Big Conversations Total
11/010 Big Conversation 15/02/11 Venue Cymru, Llandudno 65
11/050 Big Conversation 16/02/11 Optic Centre, St Asaph 68
11/060 Big Conversation 14/02/11 Glyndwr University, Wrexham 54
Grand Total 187
These events were interactive discussions amongst groups of staff from across the Health Board involving dialogue between the participants and senior executives, along with key influential leaders from the National Leadership and Innovation Agency for Healthcare and Mersey Care NHS Trust. A panel answered questions around values and then the participants worked in groups to answer two questions.
Panel Questions:
What are values?
Why do values matter?
Why is it important for BCU to be undertaking this work now?
When you see a successful organisation, leader or team in action what do you notice about
the way they work?
Participant Questions:
What inspires you to deliver the best service to patients/service users?
What are the values that best help us work together effectively?
Venue Cymru, Llandudno
Venue Cymru, Llandudno
Optic Centre, St Asaph
Optic Centre, St Asaph
Glyndwr University, Wrexham
World Café Events
The engagement work has been further developed by utilising World Cafe events to stimulate deeper conversations and determine the behaviours which will be required to demonstrate the values identified from the Big Conversation. These events included employees, volunteers and public members group.
Over coffee and cake in a relaxed environment groups answered questions around personal values and how they influenced us in giving our best for service users, drew on the table cloths and moved around the tables sharing what has been discussed around the room. Sample table cloth drawing below.
We held ten World Café Events in February, March and May, in different locations. Overall
there were a total of 127 participants.
World Café Events Total Attended
11/010 World Cafe 01/03/11 YG 14.00pm 12
11/010 World Cafe 21/02/11 BYN 10.00am 17
11/010 World Cafe 21/02/11 BYN 14.00pm 12
11/050 World Cafe 22/02/11 ABH 10.00am 7
11/060 World Cafe 25/02/11 WXM 10.00am 16
11/060 World Cafe 25/02/11 WXM 14.00pm 7
11/060 World Cafe 28/02/11 Holywell 14.00pm 10
11/050 World Cafe 02/03/11 RAH 10.00am 24
May 2011 World Café Volunteers Wrexham 6
May 2011 World Café Volunteers Glan Clwyd 16
Grand Total 127
Q3. Behaviours
HAPPY Consistency
Communication
Listened to
Understanding your team or
individuals within your Team!
Enthusiasm
Empowering
Appropriate Delegating
Sharing Knowledge
Supported Professional
Approachable
Sympathetic
COURTESY
Time Management
Respectful
Motivated
Autonomy
Trust
Intranet Forum
The Big Conversation Forum featured on the Intranet where staff could post their ideas, comments, suggestions and participate in the conversation. To date this has received 2,594 ‘views’ from the organisation.
Intranet Forum Total
Comments 21
Responses Big Conversation Team 16
Intranet Forum Views 2594
2631
http://howis.wales.nhs.uk/sitesplus/861/page/43156
Write into or email
Participants were also able to write to Tracey Amos, Training Facilitator, Abergele Training Department, Abergele Hospital, Llanfair Road, Abergele. Or email [email protected]
Big Conversation Questionnaire
A questionnaire was produced with a prize draw voucher for all employees, volunteers and service users to complete. The questionnaire asked for top five values and behaviour statements to support these. The questionnaire was produced in English and Welsh. Word search questionnaires, simple picture postcards, postcards where participants could draw their responses and flashcard games were also produced to enable full participation and engagement. Overall 301 completed questionnaires have been received in various formats.
Completed Questionnaires Total Received
Employee 263
Inpatient 3
Outpatient 12
Patient Visitor 6
Service User 4
Volunteer 5
Intranet Forum 8
Grand Total 301
Presentations
The Organisational Development Senior Management Team attended Stakeholder Reference Group, Healthcare Professionals Forum, Joint Partnership Forum and the BMA Local Negotiating Committee.
Date Presentation/Meetings Attended Total Attendance
11.03.11 Health Care Professionals Forum 12
21.03.11 Stakeholders Reference Group 15
29.03.11 Joint Partnership Forum 15
21.04.11 BMA Local Negotiating Committee 12
54
Drop in Sessions
The Training and Development team set up exhibition stands in seventeen locations including the three main hospital sites and community hospitals. Conversations were had with employees and service users. Exhibition stands were also set up in the doctors areas in line with their Grand Round events.
Drop in Sessions
HM Stanley - St Asaph Deeside Community Hospital Dolgellau Community Hospital
Glan Clwyd Hospital Mold Community Hospital Doctors Grand Round Wrexham Maelor Hospital
Colwyn Bay Community Hospital Alltwen Community Hospital Doctors Grand Round Clan Clwyd Hospital
Denbigh Community Hospital Holywell Community Hospital Doctors Grand Round Ysbyty Gwynedd
Royal Alex Community Hospital Wrexham Maelor Hospital
Llangollen Community Hospital Eryri Community Hospital
Chirk Community Hospital Ysbyty Penrhos Stanley
Flint Community Hospital Ysbyty Gwynedd Hospital
Panel Members and Facilitators
We had eight panel members over the three Big Conversation Events. Lindsey Dyer from Mersey Care Trust attended all three dates.
Lindsey Dyer Director Service Users and Carers, Mersey Care Trust
Grace Lewis-Parry Director of Governance & Communications
Jill Galvani Director of Nursing & Patient Care
Martin Jones Director of Workforce & Organisational Development
Mary Burrows Chief Executive
Christine Bamford Director of Leadership and Organisational Development NLIAH
Giles Harborne Chief of Staff MH&LD
Brian Tehan Assistant Medical Director
We used thirty six table facilitators across all of the Big Conversation and World Café events. Many of these facilitators attended a number of the events and were very supportive.
Lesley Hall Assistant Director, Employment Strategies & Practices
Amanda Spanswick Leadership/Organisation Change Development Manager NLIAH
Angela Johnson Workforce & OD
Barbara Lloyd Assistant Director Corporate Affiars
Bethan Johnson Snr Leadership & Organisational Change Dev Manager NLIAH
Damian Heron ACOS Operations & Planning
David Fletcher Associate Chief of Staff Operations Pathology
Dianne Lewis Training Facilitator
GillIan Jones Strategic Back Care
Greg Bloor Porters Manager
Heather Bebbington Head of Employment Practice & Business Support
Jane Trowman Head of Planning
Janette Hamilton Service Improvement Sister
Jill Newman Assistant Director Performance
Joy Lloyd Deputy Training & Development Manager
Kath Clarke Clinical Nurse Manager Surgical Services
Liz Childs HR Manager BSP
Llinos Thomas Acting Head of Nursing for Surgery
Mandy Hughes Support Worker Education Manager
Mark Sykes Assistant Director Organisational Development
Mary Popplewell Assistant Director Risk and Assurance
Mike Townson Equalities Manager
Muriel Vernon Training Manager
Nia Thomas Head of Organisational and Leadership Management
Pam Luckock Senior Equality Manager
Pam Roberts Trainer
Patrick Hill Deputy Director, Medical Physics
Richard Tompkins Assistant Director Workforce Development & Service Improvement
Rosemary Tuszynska Head of Learning and Education
Sally Baxter Assistant Director Strategy & Engagement (Planning)
Sally Hughes Jones Head of Equality, Diversity & Human Rights
Sandra Robinson Clark Assistant Head of Nursing
Tracey Eccles Manual Handling Manager
Barry Davies Training Administrator
Tracey Amos Training Facilitator
Joanne Williams Health Care Support Worker Education
What questions did we ask?
The Big Conversation, panel questions and sample of responses
What are values?
Mary Burrows - They are what help me live day to day, integrity, honesty, truth, equality, duty, service to others, how we behave and respect one another.
Jill Galvani - Upbringing – knowing what is right and wrong. Putting others before yourself – caring –often from a religious tradition, doing your best at all times – being a good citizen. Fundamental value – treat others as you would like to be treated yourself. This translates to the workplace through wisdom, kindness, fairness, equality, dignity, compassion – passionate about this approach.
Martin Jones - Values are a set of guiding principles, a statement of issues of conduct in how we behave. We all have personal values. I hope that we get a set of value statements for organisation of 16000 people in BCU – set of values that will find the glue that holds the organisation together, the reason why we came into public service. Guiding principles, statements of conduct that we will not give up no matter how hard times are, things that we hold dearly.
Why do values matter?
Lyndsey Dyer– In essence need to start from point of view of patient, staff, director etc – about common humanity of each and every person and I think that big health care organisations forget it is not about differences but what is common between us. The values that are common we would expect to see those values anywhere in the world. We need to judge ourselves by international standards of good practice. If you feel part of international movement, it will give you the courage to be brave sometimes to stand up for what is right.
Martin Jones – Set of words that show what we are about and as a sense of inspiration bind us together –. At times when things go wrong we need guiding statements to keep us honest – values can help in defining quality of the service we want, guidance where we draw a line eg: some of the words respect dignity compassion.
Mary Burrows - Need courage for standing up for what you believe, take risks. Be compassionate and nice to people - all individuals have common purpose, a right to be here. Fun and humour are important.
Why is it important for BCU to be undertaking this work now?
Giles Harborne –We need to get something more from work than just pay – personal values are important and as an organisation we need to support people and realise their values as a health professional.
Brian Tehan – We have a lot of work still to establish BCU and we are now at a really good point in development in establishing core values to move forward.
Grace Lewis Parry – Values will help us have a conversation, new vocabulary – new process to build on.
When you see a successful organisation, leader or t eam in action what do you notice about the way they work?
Chris Bamford – Team – good teams talk about patients all the time, heart of the dialogue less effective teams don’t do. Can do attitude means we can do this a bit better. Everyone knows their role within team, doesn’t matter what profession, clear what they are there to do, leadership can pass to another member of team depending on what they are good at. Care about other team members, who they are at work and who they are outside work, care and compassion. Wider remit, leadership need clear leadership from top but comes from all levels – need to be clear about direction. Can do better – fostering people’s development, continue to grow and develop them
Brian Tehan – Alignment of vision and purpose, taking pride as a team in the results. Mutual understanding and appreciation of each individual in the team and the contribution that they make.
Responses to table feedback and questions
Q. How do we now involve patients?
Mark Sykes - Will be organising focus groups, with service users, patients.
Q When values decided how will they be measured to show how achieve?
Martin Jones - Value is a statement of conduct of what we what to happen, hold on to, behavioural standards for the values, feedback from service users could be a mechanism. Like to think that if we agreed 3-5 I could go into any part of organisation and say what does this mean to you? If we have touchstones the way people interpret is important we need to know what we mean across diverse organisation if we are clear about the behavioural standards we will have external monitoring relationships as well. Staff survey, staff attitudes, one thing we should ask in the future if we define this ask staff whether we live up to it.
Q How do we highlight success – pick out values – a lways focused on the negative aspects?
Grace Lewis Parry – Patient stories, patient experience will help us understand and identify our success. It’s all about the story that you tell about what it is like to be an employee of the health board – this is where our success can spread as well and be used in a positive way. Social networking needs to be explored – twitter, face book and the like to sell ourselves and our health board.
Overall Feedback
Mary Burrows - Brilliant stuff, very humbling. To me the key words are togetherness and rights and responsibilities – it isn’t us and them. If we are to do the best and serve we need to get rid of ‘us and them’ mentality. We all have contribution to play. Rights and responsibilities- we focus on the rights of the individual and sometimes don’t focus on responsibilities. Other point is about autonomy – we are all autonomous we don’t need permission to do the right thing for patients. Everyone has the power to improve service.
Martin Jones – Our responsibility is to help people see the link between service improvement and improving well being for staff. One way to help this is to make sure we all have a voice in how we run services, everyone’s view needs to be taken into account.
Big Conversation table questions
Question 1 : What inspires you to deliver the best service to patients/service users?
Question 2: What are the values that best help us work together effectively?
Keyword results below, top 10 highlighted in yellow.
Question 1 Count of Key Words
Question 2 Count of Key Words
Key Words Total Percentage Key Words Total
Percentage
Autonomy 4 1.3% Autonomy 9 2.8%
Brave 1 0.3% Brave 2 0.6%
Clarity 3 1.0% Clarity 7 2.1%
Communication 13 4.2% Communication 24 7.4%
Consistency 2 0.6% Consistency 1 0.3%
Courageous 4 1.3% Courageous 5 1.5%
Dignity 3 1.0% Dignity 4 1.2%
Do the right thing 2 0.6% Diversity 6 1.8%
Empathy 4 1.3% Do the right thing 3 0.9%
Empowerment 9 2.9% Empathy 6 1.8%
Equality 1 0.3% Empowerment 9 2.8%
Fairness 3 1.0% Equality 11 3.4%
Feedback 23 7.4% Fairness 6 1.8%
Flexibility 1 0.3% Feedback 14 4.3%
Honesty 3 1.0% Flexibility 4 1.2%
Humanity 4 1.3% Honesty 12 3.7%
Humour 1 0.3% Humanity 2 0.6%
Integrity 2 0.6% Humour 4 1.2%
Knowledge/Education 21 6.8% Integrity 2 0.6%
Leadership 11 3.6% Knowledge/Education 17 5.2%
Listening 5 1.6% Leadership 14 4.3%
Make a difference 18 5.8% Listening 7 2.1%
Making it happen 1 0.3% Open/transparent 7 2.1%
Open/transparent 1 0.3% Patient 23 7.1%
Patient 48 15.5% Pride 4 1.2%
Pride 18 5.8% Professionalism 5 1.5%
Professionalism 2 0.6% Respect 27 8.3%
Respect 9 2.9% Responsibility/Accountability 8 2.5%
Responsibility/Accountability 9 2.9% Teamwork 21 6.4%
Teamwork 26 8.4% Transparency 2 0.6%
Trust 5 1.6% Trust 10 3.1%
Unity 11 3.6% Unity 20 6.1%
Valued 41 13.3% Valued 30 9.2%
(blank) (blank)
Grand Total 309 Grand Total 326
Selection of Participant Quotes and Phrases
Communication
Effective communication - makes easier to contact people and connect, share and inform, service user involvement, grow appreciative of other roles, keep it simple, make it easy to understand, big words are a barrier, invite feedback and encourage.
Communication, needs improving from the bottom up, top down and sideways, clarity.
Communication, patients, carers, staff partners, face to face
Communication: bread and butter not a nice to have, meaningful, not tick box, two way process
Knowledge/Education
Share of working knowledge, information, skills, cooperation all pieces of the jig saw
Need to be more business like and focus on scientific/cutting edge with university links/research/academic network.
Investment in staff – given space / ability to influence / tools to do job
Knowledge through experiential learning
Unity
Belonging and unity to the whole organisation rather than separately. ie CPG
Common goals - unity
Like minded values set that everyone signs up to and feels part of.
Commonality of purpose
Respect
Respect, care for everyone, irrespective of background (drug user and chief executive – power differential).
Deal with people as you want to be dealt with.
Respect for each others jobs.
Respect needs to be mutual
Respect: for others – staff and patients – valuing others and valuing and understanding each others role to contribute to effective team working.
Pride
Pride in being a health care professional
Reputation both personal and organisational
Pride in work, done my best, do extra mile, done the right thing.
Belonging, feel that I belong and have pride in what you do.
Valued
Valuing contributions of all team members
Recognition and acknowledgement, being valued and trusted. Good will is two way.
Appreciation: motivates you, self worth, being valued
Family friendly - work life balance - values members as individuals as well as organisation
Patient Care
Delivering best care – making a positive difference
All staff are potential service users, therefore provide a service we would expect. Patient and client focused.
Patient expectations and patient centred, high quality service, quick easy access, be heard and listen, choice, confident in staff, professional care, best available care
Caring organisation
Teamwork
Understanding the roles of others that impact your work.
Nothing about me 'without me' in all elements of the organisation.
Strong relationships within teams. Support each other/become close knit.
Team Working – supported by development
Leadership
Strong leadership support the direction of staff/change. If staff concerns are listened to and feel they are in an environment to deliver excellent care.
Must be led from the top and modelled throughout the organisation.
Confidence in management
Role model and good leader, values set and aligned to our own.
Feedback
Positive feedback from patients, carers, colleagues, relatives, manager, users
Feedback – inspiring you to do better (appreciate inquiry). Sustains good practice.
Sharing good practice
Hearing about the good news – patient care and good experiences
Honesty
Open and honest with each other.
Honesty: with each other to produce effective team working.
Self awareness, honesty
Empowerment
Feeling empowered, individually and as a team.
Empowering staff to shape the future
Empowerment, being flexible, trusted, decision making.
Empowerment / patients
Total
0
5
10
15
20
25
30
35
Aut
onom
y
Bra
ve
Cla
rity
Com
mun
icat
ion
Con
sist
ency
Cou
rage
ous
Dig
nity
Div
ersi
ty
Do
the
right
thi
ng
Em
path
y
Em
pow
erm
ent
Equ
ality
Fai
rnes
s
Fee
dbac
k
Fle
xibi
lity
Hon
esty
Hum
anity
Hum
our
Inte
grity
Kno
wle
dge/
Edu
catio
n
Lead
ersh
ip
List
enin
g
Ope
n/tr
ansp
aren
t
Pat
ient
Prid
e
Pro
fess
iona
lism
Res
pect
Res
pons
ibili
ty/A
ccou
ntab
ility
Tea
mw
ork
Tra
nspa
renc
y
Tru
st
Uni
ty
Val
ued
(bla
nk)
Total
Question 2 Count of Key Words
Key Words
World Café table questions
Question 1: What are your values?
Question 2: Which is most important to you, rank your values in order 1-5?
Question 3: What behaviours would we need to deliver these values?
What are your values Top 10 What behaviours Top 10
Communication Communication/Listening
Equality Honesty
Honesty Knowledge/Education
Knowledge/Education Leadership/Approachable
Patient Care Openness
Recognition Respect
Respect Teamwork
Teamwork Valued
Trust Patient Care
Valued Trust
Selection of Participant Quotes and Phrases
What are your values Top 10
Communication
Honest and open communication with all.
Communication - positive language
Equality
Treating others as you would like to be treated yourself
Equality – treatment of staff
Honesty
Honesty in communications
Honesty – transparency (within your own role)
Knowledge/Education
Development - staff training knowledge - improved customer service
Sharing knowledge skills and learning
Patient Care
Giving the best, being the best, gold star service
Doing the best job you can for the patient – directly and indirectly.
Recognition
Recognition for work done, receiving positive feedback.
Recognition for the work we do.
Respect
Unconditional positive regard for all.
Back to basics: respectful, smile, common courtesy.
Teamwork
Working in partnership with colleagues, team effort.
Sense of belonging
Trust
Trust – you trust me and I will trust you, 2-way
Doing what you said you will do
Valued
Recognise peoples individual expertise 'All cogs in the same wheel'
Being appreciated by patients, staff, management, colleagues:
Behaviours Top 10
Communication/Listening
Being polite, using respectable language, tone of voice, pace people can understand
Effective, two-way communication, eg., team meetings (not corporate brief), engagement.
Honesty
Optimistic and enthusiastic, tempered with honesty and realism – balanced view.
Be honest with staff and patients.
Knowledge/Education
Inspiration through mentorship
Offer equal opportunity to receive training and development.
Leadership/Approachable
Leaders should support staff to have a good work life balance.
Visibility – important to have visible leadership.
Openness
Being willing to listen/open minded
Clarity, transparency – communication to let people know impact of structures
Respect
Being respectful of all, the person and the patient
Respect professional views and experience
Teamwork
Understanding your team and individuals within your team.
Listening/understanding/appreciating, supportive (to teams), social aspect important – respect for each other.
Valued
Motivate staff – respect professionals views and experience
Being treated fairly - treating others as you want to be treated yourself
Patient Care
Treat others how you would expect you or your family be treated.
All staff to help identify areas of effectiveness and efficiency whilst maintaining patient safety
Trust
Trust your instinct
Trusting Relationships.
Top Values
Data has been collected from the Big Conversation Events, World Café Events, Intranet Forum Feedback, Drop in Sessions and completed questionnaires to give an overall scale of values and importance. Scale shows number times word said.
Over 200 100-200 50-100 25-50
Communication Honesty Empowerment Dignity
Patient Care Knowledge/Education Feedback Empathy
Respect Leadership Pride Fairness
Teamwork Trust Recognition Listening
Valued Equality Unity Make a difference
Autonomy Openness
Responsibility/Accountability
Transparency
Focus Group
Sixteen members of the facilitation team for the above events met as a six thinking hats methodology focus group. This group worked with the top values scale as above to determine, values, behaviour statements and grouping of values.
Betsi Cadwaladr University Health Board
Workforce Engagement Strategy
1.0 Introduction
1.1 This paper supports the paper on defining values for the Health Board
and makes recommendations on future interventions to build
workforce engagement.
2.0 Background
2.1 Workforce engagement is increasingly seen as a critical factor in
determining organisational success. Engagement can be defined as:
‘……a positive attitude held by the employee towards the
organisation and its values. An engaged employee is aware of
business context and works with colleagues to improve performance
within the job…….’
(D. Robinson, S. Perryman, S. Hayday, The Drivers of Employee
Engagement, Report 408, Institute for Employment Studies, 2004)
Robinson et al go onto say that organisations must work hard to
nurture maintain and grow engagement based on principles of trust,
shared values and defined autonomy.
2.2 The Roffey Park Institute’s model of employee engagement (J.
Gifford, L. Finney, J. Hennessy, S. Varley, The Human Voice of
Employee Engagement. Roffey Park Research 2010) identified three
components of employee engagement:
• Engagement with the organisation (essentially about pride and identification)
• Engagement with the job role (essentially about contribution and involvement)
• Engagement with colleagues (essentially about relationships and respect)
2.3 In this model the crucial test is whether the employee sees a
‘payback’ for the engagement in terms of being valued, respected
and making a difference at work. This is about the employee
experience; is the employer seen as fair, reasonable and appreciative
and are employees supported, trusted and valued? In return is the
employee motivated to deliver discretionary effort?
3.0 The Case for Engagement
3.1 There is a clear evidence base that higher levels of individual and
organisational performance result from higher levels of engagement.
In addition employee well-being is correlated to degree of
engagement.
3.2 A Chartered Institute of Personnel & Development research
programme (reported in ‘Creating an Engaged Workforce.’ CIPD
January 2010) found the following outcomes of effective
engagement:
1. higher individual performance levels through appraisal 2. innovative work behaviour 3. employee satisfaction 4. higher levels of individual well being (coping with demands
and avoiding burnout) 3.3 Engagement is a key factor in effective team working. Findings from
the Health Care Team Effectiveness Project (West et al 2003)
indicated a correlation between team working and effectiveness:
1. better clinical outcomes/quality of care 2. higher levels of innovation 3. cost effectiveness 4. lower levels of stress 5. lower staff turnover
3.4 The MacLeod Review (Engaging for success: enhancing performance
through employee engagement, A report to Government, Crown
Copyright 2009) reported research from Gallup in 2006 that business
units with engagement scores in the bottom quartile averaged higher
levels of employee turnover and accidents, those with engagement
scores in the top quartile averaged higher customer advocacy,
higher productivity and higher profitability. Similar research from
Tower- Perrins HR in 2006 linked profitability with engagement.
3.5 Other outcomes of engagement referred to by MacLeod are:
1. lower sickness 2. understanding of customer needs 3. employees acting as advocates for their organisation 4. companies in the ‘Best Companies to Work for’ Awards in the
period 2004 – 8 increased turnover by 94% and profits by 315% 5. the work of Beverley Alimo-Metcalfe at Bradford University on
engagement and performance in 46 NHS Mental Health Teams. Her findings linked engagement and performance. They quote her as follows:
6. ‘we were able to provide evidence that engaging leadership does, in fact, predict productivity…….(it) increases employees’ motivation, job satisfaction and commitment while reducing job-related stress.’
4.0 Creating Engagement
4.1 The case for engagement is compelling. In MacLeod’s view it should
be placed at the heart of business strategy. The report concludes
that engagement is crucial to sustainable success: ‘more people
need to ‘get it’ and more people need to do it.’
4.2 The CIPD and MacLeod Research identify some common enablers of
engagement:
1. finding purpose and meaning in the job (an employee believing it is important and s/he can make a difference)
2. leadership behaviour at all levels 3. senior leadership articulating a clear vision and values and
supporting through communication 4. positive perceptions of line managers 5. a ‘strong sense of employee ‘voice’’, i.e. that employees have
the opportunity to contribute to and influence key decisions affecting them in the workplace.
6. the quality of HR practices and policies (particularly personal review, training and development and career management).
4.3 Further CIPD Research (Locus of Engagement, Understanding what
employees connect with at work, CIPD 2011) suggests that employees
engage differentially with varying aspect of work. It concludes the
following:
1. Highest engagement with the job (variety, autonomy and meaning being key)
2. High engagement with line managers and colleagues (contribution, voice and working relationships)
3. Moderate engagement with the organisation (e.g. the employment relationship, and organisational reputation).
4. Low engagement with external partners, stakeholders etc. 4.4 This finding suggests that a workforce engagement strategy for the
Health Board should concentrate predominantly on
• Team working • The line manager/employee relationship • Employee development • Leadership behaviours These issues are explored further in section 7 below
5.0 Current Level of Workforce Engagement within BCUHB
5.1 The Health Board does not routinely collect evidence about the level
of Workforce Engagement. Therefore it is currently heavily dependent
on anecdotal evidence. It is recommended that more rigorous
collection of evidence is used-to assess engagement.
5.2 The last Staff Attitude Survey was in 2007 and therefore of limited
relevance. A recent 1000 Lives Safety Culture survey has been
conducted and analysis of responses will be circulated shortly.
5.3 The Health Board currently reports on a range of workforce metrics.
Some of the measures (e.g. turnover and sickness) are proxies for
engagement but it is very difficult to draw firm conclusions from them
about the level of engagement. The development of reliable
measures will be an early priority.
5.4 The Health Board is seeking to develop a set of measures that will
provide evidence of employee relations effectiveness (e.g. numbers
of grievances and speed of resolution). Work will be necessary with
Trade Union partners to identify measures.
5.5 It is not therefore possible to determine objectively the level of
engagement. However anecdotally the current level of employee
engagement has been significantly affected by organisational
change particularly in respect of:
1. organisational attachment (traditional boundaries, working relationships and teams have been affected)
2. uncertainty and change in terms of organisational structure 3. reduced proximity of senior leaders to their teams 4. difficulties of communications across a much larger organisation 5. changes to governance, policy and procedural arrangements 6. lower compliance with core people management processes
such as Personal Development reviews. In summary, this can be characterised as a state in which employees
have reduced confidence and capability in their ability to
understand their changing environment and to improve services.
6.0 Current Workforce Engagement Activities
6.1 The Health Board has a number of current activities that are related to
engagement as detailed below:
6.2 Pre-Employment
• careers information / liaison • work experience
6.3 Employment
• induction & orientation • Partnership Forum/LNC • Partnership arrangements • Service reviews-engagement processes • KSF and PDR processes • Leadership development programmes • Medical Appraisal and job planning • 1000 Lives surveys • Big Conversation-development of values • Safety Walkrounds • Medical &Dental Staff Committee • Charitable giving, Wales in Africa • Long Service Awards • Staff Achievement Awards • NHS Wales Awards • Corporate Health Standard • Communications
• Board of Directors update • Noticeboard/’Talk About’ • Mail to Mary/Rumour Hotline etc
6.4 Post-Employment
• Pre-retirement programmes
• Retirement Fellowship 7.0 Workforce Engagement Objectives for BCU
7.1 The CIPD Research Report “Locus of Engagement: understanding
what employees connect with at work” (May 2011) identified four
implications for practice.
1. Engagement is with something (it has a specific “locus”) – it is important to find out the locus or loci.
2. Engagement can be with many loci – what is the balance of levels of engagement to determine where the organisation should concentrate its efforts.
3. Engagement varies over time – it needs to be assessed and reviewed.
4. The link of engagement to performance depends on organisational context – the challenges facing the organisation at the time.
7.2 Without specific research into the state of engagement within BCUHB
it is not possible to define the loci objectively. However, there were
some clear messages from members of staff attending the Big
Conversation, World Café and drop-in sessions. These are identified in
7.3 below
7.3 1. The strongest pride and attachment felt by employees is at the level of the NHS, profession/vocation and own team rather than at the organisational level.
2. Nonetheless, it was felt important for the Health Board to stand for certain values which would be present at all levels of the organisation.
3. The importance of making a difference through the employee’s job and team was widely-shared.
4. The role of senior leaders in helping staff make sense of a changing environment was important.
5. Leadership behaviour was the crucial factor in determining whether staff felt supported and encouraged in contributing their ideas and energy. This was summed up as whether staff had ‘permission’ to make decisions and do the right thing for the service user. Therefore innovation and service transformation would be enabled or hindered by leadership behaviour.
7.4 These messages support a conclusion therefore that the future
workforce engagement interventions for the Health Board should be
focussed on the following objectives:
1. Cementing and embedding the values created by the workforce
throughout the Health Board.
2. Ensuring every member of staff is located in a high-performing
team.
3. Strengthening the line manager/employee relationship through
effective application of people-management policies and
practices.
4. Developing a consistently high level of leadership across the organisation through leadership development programmes that
emphasise effective behaviours.
5. Ensuring that employee development processes are fairly,
comprehensively and effectively applied to maximise individual
contribution (objective-setting, KSF outline, Personal Development
Review/Personal Development Plan). Consideration should be
given to whether a commitment to the Investors in People
Standard and programme for the Health Board would be
beneficial.
6. Strengthening partnership working at all levels of the organisation to strengthen the employee voice in decision-making.
7.5 A full action plan with agreed interventions will be developed but it is
likely to include the following elements:
1. Regular organisational culture surveys 2. Consideration of the Investors in People Standard 3. Leadership development programmes to embed the values
and behaviours co-created by the workforce
4. Team working development programmes
5. Joint training in partnership working 6. Effective monitoring of compliance with employee
development processes.
8.0 Recommendations
8.1 The Board is asked to support the conclusions in Section 7.0 of the
paper and objectives outlined in section 7.4
8.2 Subject to Board approval the Director of Workforce &OD would lead
implementation of an action plan to address the objectives. This
action plan would include definition of success measures, cultural
assessment and targeted interventions such as those identified in 7.5
above.
8.3 The Executive Team would establish the programme management
arrangements, in partnership, to drive this change.
Mark Sykes
Assistant Director, Organisational Development
May 2011
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
EQUALITY IMPACT ASSESSMENT FORMS
Form 1: Preparation
1.
What are you equality impact
assessing?
Developing Values and Behavioural Statements for BCUHB - Strategic Recommendations Paper
2.
Aims and Brief Description of what you
are assessing.
Assessment includes ensuring inclusivity of all stakeholders within the work carried out to co-create the values and behaviours for the organisation.
3.
Who is responsible for the Policy/work
you are assessing?
Workforce & OD Director
Assistant Director of OD
4.
Who is Involved in undertaking this
EqIA?
Assistant Director of OD
Head of OD
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
5.
Is the Policy related to other
Policies/areas of work?
The agreed values and behaviour statements will need to be integrated into areas such as Recruitment and retention strategies, policies and procedures; Induction policy; Staff Surveys; patient satisfaction questionnaires; management code of conduct etc.
6.
Who are the key Stakeholders?
All employees of BCUHB
All service-users and external agencies working with BCUHB
7.
What might help/hinder the success of
the Policy?
Engagement and buy-in from the Board and all employees is crucial to the success of integrating the values and behaviours into day-to-day work, interaction with colleagues, service-users and external agencies.
Form 2: Information Gathering
Ag
e
Dis
ab
ilit
y
Ge
nd
er
Ge
nd
er
Re
ass
ign
me
nt
Pre
gn
an
cy &
Ma
tern
ity
Ra
ce/E
thn
icit
y o
r
Na
tio
na
lity
Re
lig
ion
or
Be
lie
f
Se
xu
al
Ori
en
tati
on
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Form 2 Page
2
The Human Rights Act contains 15 rights, all of which NHS organisations have a duty to act compatibly with and to respect, protect and fulfil. The 6 rights
that are particularly relevant to healthcare are listed below. For a fuller explanation of these rights and other rights in the Human Rights Act please refer
to the Toolkit Appendix A: The Legislative Framework.
Depending on the Policy you are considering, you may find the examples below helpful in relation to the Articles.
Is the policy relevant to the public sector general duty relating to each equality
characteristic? Answer Yes or No in each box as appropriate (for a definition of
Relevance, refer to Toolkit)
In other words, is the Policy relevant to:
• eliminating discrimination and harassment in relation to:
Y Y Y Y Y Y Y Y
• advancing equality of opportunity in relation to:
Y Y Y Y Y Y Y Y
• promoting good relations and positive attitudes in relation to:
Y Y Y Y Y Y Y Y
• encouraging participation in public life in relation to disability
Y
In relation to disability only, does the Policy take account of difference, even if
it involves treating some individuals more favourably? Y
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Yes No
Consider, is the Policy relevant to:
Article 2 : The right to life
Example: The protection and promotion of informed consent
�
Article 3 : The right not be tortured or treated in an inhuman or degrading way
Examples: Issues of dignity and privacy; the protection and promotion of the safety and welfare of patients and staff;
the treatment of vulnerable groups or groups that may experience social exclusion, for example, gypsies and travellers;
Issues of patient restraint and control
�
Article 5 : The right to liberty
Examples: Issues of patient choice, control, empowerment and independence; issues of patient restraint and control
�
Article 6 : The right to a fair trial
Example: issues of patient choice, control, empowerment and independence
�
Article 8 : The right to respect for private and family life, home and correspondence;
Examples: Issues of dignity and privacy; the protection and promotion of the safety and welfare of patients and staff;
the treatment of vulnerable groups or groups that may experience social exclusion, for example, gypsies and travellers;
�
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
the right of a patient or employee to enjoy their family and/or private life
Article 11 : The right to freedom of thought, conscience and religion
Examples: The protection and promotion of the safety and welfare of patients and staff; the treatment of vulnerable
groups or groups that may experience social exclusion, for example, gypsies and travellers
�
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Form 2
Page 3
Equality Characteristic
Please list here details of any Information Gathered e.g. Reports, Statistics, Web links etc that are relevant to your
Policy and/or the Characteristics
Age
Disability
Gender
Gender Reassignment
Pregnancy & Maternity
Race (including Ethnicity and
Nationality)
Religion or Belief
Sexual Orientation
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Welsh Language
Human Rights
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Form 3: Assessment of Relevance and Priority
Scoring Chart A: Evidence Available Scoring Chart B: Potential Impact Scoring Chart C: Impact Decision
Equality Strand Evidence:
Existing Information to suggest some
groups affected. Gathered from Step 2.
(See Scoring Chart A)
Potential Impact:
Nature, profile, scale, cost, numbers affected,
significance.
Insert one overall score
(See Scoring Chart B)
Decision:
Multiply ‘evidence’ score by ‘potential
impact’ score.
(See Scoring Chart C)
Age 1 +3 3
Disability 1 +3 3
Gender 1 +3 3
Gender
Reassignment
1 +3 3
Pregnancy &
Maternity
1 +3 3
Race/Ethnicity or
Nationality
1 +3 3
Religion or Belief 1 +3 3
Sexual
Orientation
1 +3 3
Welsh Language 1 +3 3
Human Rights 1 +3 3
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
3 Existing data/research -3 High negative -6 to -9 High Impact (H)
2 Anecdotal/awareness data only -2 Medium negative -3 to -5 Medium Impact (M)
1 No evidence or suggestion -1 Low negative -1 to -2 Low Impact (L)
0 No impact 0 No Impact (N)
+1 Low positive 1 to 9 Positive Impact (P)
+2 Medium positive
+3 High positive
Form 4: Outcome Report and Action Plan
Organisation: BETSI CADWALADR UNIVERSITY HEALTH BOARD
Name: Mark Sykes
Title: Assistant Director of OD
Sponsored by:
Department: W&OD
Policy Title: (Copy from Form 1) Developing Values and Behavioural Statements for BCUHB - Strategic
Recommendations Paper
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Brief Aims and Objectives of
Policy: (Copy from Form 1)
Assessment includes ensuring inclusivity of all stakeholders within the work carried out to co-
create the values and behaviours for the organisation.
Yes No Is the Outcome of the
Initial Screening to
proceed to full Equality
Impact Assessment?:
Record Reasons for Decision:
Not proceeding to a full equality impact assessment as only positive impact has been identified across all the
characteristics.
Yes No If no, are there any issues
to be addressed?
Record Details:
Is the Policy Lawful? Yes No
Yes No Will the Policy be
adopted?
If no, please record the reason and any further action required:
�
�
�
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Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Yes No Are monitoring
arrangements in place?
Refer to Action Plan (see below) Refer to Engagement Strategy
Name: Mark Sykes
Title: Assistant Director of OD
Who is the Lead Officer?
Department: W&OD
Review Date of Policy: 01/09/2012
Name Title Signature
Mark Sykes Assistant Director of
OD
Nia Thomas Head of O&LD
Signature of all parties:
Please Note: An Action Plan should be attached to this Outcome Report prior to signature
�
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Form 4: Action Plan
You are advised to use the template below to detail any actions that are planned following the completion of EqIA. You should include any remedial changes
that have been made to reduce or eliminate the effects of potential or actual negative impact, as well as any arrangements to collect data or undertake further
research. This Action Plan should be completed in conjunction with the Outcome Report.
Response Proposed Actions
Lead Officer
Identified
Timescale Progress
1. Will the Policy be adopted? Yes Submitted to June Board
Mark Sykes June Board
2. If No please give reasons and
any alternative action(s) agreed:
(If the Policy is not to be adopted
please proceed to step 9).
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Response Proposed Actions
Lead Officer
Identified
Timescale Progress
3. How will the Policy be
monitored?
Through the actions identified within the Engagement Strategy
As per Engagement Strategy
Mark Sykes
Nia Thomas
4. What monitoring data will be
collected?
As per Engagement Strategy
5. How will this data be
collected?
6. When will the monitoring data
be analysed?
7. Who will analyse the data?
8. What changes have been made
to the Policy as a result of EqIA? None
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
Response Proposed Actions
Lead Officer
Identified
Timescale Progress
9. Where a Policy may have
differential impact on certain
groups, state what arrangements
are in place or are proposed to
mitigate these impacts?
N/A
10. Justification : for when a
policy may have a negative impact
on certain groups, but there is
good reason not to mitigate
N/A
11. Provide details of any actions
planned or taken to promote
equality
12. Describe the arrangements
for publishing the EqIA Outcome
Report
Attached as part of the report submitted to Board
Publicised on the Intranet with the Values & Behaviours document
Nia Thomas
13. When will the Policy be
subject to further Review?
01/09/2012
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
NOTE: If your decision recorded above is not to proceed to a Full Equality Impact Assessment, then you do not need not complete the following forms (5,6 and
7)
Note: For detailed guidance on the completion of these forms, please refer to Chapter 3 of the Toolkit that is available on the Equality pages of the BCUHB Intranet site.
FORMS 5, 6 AND 7 TO BE USED ONLY FOR FULL EQUALITY IMPACT ASSESSMENT
Form 5: Examine the Information Gathered So Far
1.
Do you have adequate information?
Refer to Form 2 : Information Gathering for assistance
2.
Can you proceed with the Policy during EqIA?
3.
Does the information collected relate to all equality
strands?
4.
What additional information (if any) is required?
WP7 Version: 4 Page 53 of 57
5.
How are you going to collect any additional
information needed?
State which representative bodies or other organisations or
individuals you will be liaising or engaging with in order to
achieve this
Form 6: Judge/Assess the Potential Impact of the Policy across the Equality Strands
Detail below whether you have identified any positi ve/adverse/neutral impact for any of the following groups :
WP7 Version: 4 Page 54 of 57
Equality Strand/Group
Key Equalities Legislation or Policy
Adv
erse
Pos
itive
Degree of Potential Impact:
High (H)
Medium (M)
Low (L)
Comments
Age
Disability
Gender
Gender Reassignment
Pregnancy & Maternity
Race
Religion/Belief
Sexual Orientation
Equality Act 2010
Welsh Language Welsh Language Act 1993
WP7 Version: 4 Page 55 of 57
Human Rights Human Rights Act 1998
WP7 Version: 4 Page 56 of 57
Form 7: Consider Any Alternatives to the Policy which will Reduce, Eliminate or Mitigate any Adverse Impact (As Identified in Form 6)
1.
Describe any mitigating actions taken to
reduce negative/adverse impact
2.
Is there a strategy for dealing with any
unavoidable but not unlawful negative impacts
that cannot be mitigated?
WP7 Version: 4 Page 57 of 57
3.
Describe any actions taken to maximise the
opportunity to promote equality, ie: changes
to the Policy, regulation, guidance,
communication, monitoring or review
4.
What changes to the Policy have been made as
a result of conducting this EqIA?