red - implementation date passed management action not ... and risk...update as at jan 2017. pilot...

1

GUIDANCE NOTES Red - Implementation date passed management action not complete

Internal Audit Recommendations / Actions Log Orange - Action not on target for completion by agreed/revised date

October 2017 Yellow - Action on target to be completed by agreed/revised date

Ref Date added Issue Recommendation Priority Management Action Agreed

ResponsibleExecutiveLead/ManagementLead

Original Agreed Implementation DateRevised Implemen-tation Date

Status Progress Actions Completed Issues Arising This Period

106 May-12 2.3 From a sample of 15 Velindre and 15 PHW Changes Forms the testingshowed the following( for PHW):• 1 form for a change in hours did not show the original hrs that theindividual worked.• It took 50 days from the effective date for one form to be authorised by themanger.• Four changes forms were not signed by the employee to certify theaccuracy of the information.Changes are not expedited in a timely manner which could lead toover/underpayments or inaccurate staffing information.Absence of a satisfactory audit trail.

Trust Management must be reminded of the need to ensure that all changesforms are properly completed and signed / authorised in a timely manner.

LOW As 2.1 above Ruth Davies Mar-14ReferenceNo

Date Added to log Recommendation details taken from Internal Audit Report. Assigned in theIA report

Management Action details taken from Internal AuditReport.

Executive Lead Date will be inlcuded here. Please use appropriate'Fill Colour' inaccordance with thekey above.

Executive lead should make ajudgement on currentprogress (delete asappropriate):

Improving

No Change

Declining

This will contain specific actions that have been taken towards addressing the issue e.g.

• A schedule of all academic staff that provided sessional work/service for the organisationand seconded individuals from other health bodies is in place.

This should be used to give a summaryof any issues that have occurred sincethe last meeting/update and the actionshave been taken to mititgate them e.g.

• No issues arising in the period; or • Work was delayed due to................The issue has been discussed in thesenior management team and this willbe dealt with as a matter of priority.......

2

Next Steps & Expected Milestones

This section should be used to identify the next steps that willbe taken to achieve the recommendation. Realistic milestonesshould also be provided that can be reported upon andmeasured in future updates. These milestones must relate tothe agreed implementation date, or where this is not achievableappropriate justification should be provided. Do not duplicatenarrative provided in other columns E.g.

The service is on target to meet the agreed implementation dateand will:• Prepare a schedule of all academic staff that provide sessionalwork/service for the organisation by November 2017.............

or• The agreed implementation target of May 2017 will not beachieved due to........... We are addressing this by...........

Appendix 2

Cwm Taf MorgannwgInternal Audit Recommendations / Action Log - June 2020

Recommendations by Priority & Status

Priority

TOTAL

ImplementationDate passed

Action not ontarget

Action on targetAction proposedfor completion

High 55 20 0 1 34

Medium/Low 104 24 0 4 75

44 0 5 109

Progress Recommendations by Executive Lead & Status

Total Recommendations Executive Lead

Total

ImplementationDate passed

Action not ontarget

Action on targetAction proposedfor completion

New RecommendationsChief Executive 1 1 0 0 0

ImprovingDirector of CorporateGovernance

27 6 0 0 21

No Change Director of Finance 18 1 0 1 13

Declining Director of Nursing 4 2 0 0 2

Director of Operations 32 9 0 0 23

Director of Planning &Performance

33 11 0 0 22

Director of Primary,Community & MH

18 8 0 0 10

Director of PublicHealth

7 2 0 4 1

Director of Workforce& OD

1 0 0 0 1

Medical Director 16 0 0 0 16

Recommendation by Status

Implementation Datepassed

Action not on target

Action on target

Action proposed forcompletion

4

CTM Red -Implementation datepassedmanagement action notcomplete

InternalAuditRecommendations /ActionsLog

Orange -Action noton target forcompletionbyagreed/revised date

[date] Yellow -Action ontarget to becompletedbyagreed/revised date

Green -ActioncompleteBlue - Actionto beremovedand replacedbysubsequentaction

Ref Dateadded Issue Recommendation Priority Management Action Agreed

ResponsibleExecutiveLead/Management Lead

Committee/Group

OriginalAgreedImplementation Date

RevisedImplementation Date

RevisedImplementation date

Status Progress Actions completed Issues Arising ThisPeriod Next Steps & Expected Milestones

Review of Orthopaedic Services (2016)R1 Apr-15 Health Boards should ensure

that clear referral guidelinesare implemented andadhered to, and thatappropriate alternativeservices are available andaccessible which best meetthe needs of the patient.

High The Health Board has established an orthopaediccare collaborative group, which will take forwardthe recommendations of the National OrthopaedicPlanned Care Programme. This will include areview of referral routes and what services areavailable.

Director ofOperations

Oct-15 Sep-16 Completed Sept 2016 Update - The review of data has been delayed dueto difficulties producing a revised dataset. This has now beenresolved and the September meeting will review progress todate and produce recommendations for any changes inservice model going forward. Streamlining of referral routesinto physiotherapy with be included in this months priorities.March 2017 - Job advert in progress for CMATS clinical lead inSports & Exercise Medicine.

March 2016 Update - A sub group of the Planned CareProgramme board was set up in December 2014 - theCMATS Task & Finish group. The group has revised referralpathways into the health board for all orthopaedics/MSKconditions. A single point of referral, traiged weekly by amulti-disciplinary team to ensure patients are directed to themost appropriate service, including sports and exercise/physiotherapy/ dietetics/podiatry/orthopaedics. Nextpriorities for the group are to work with primary care on asingle referral form that covers all of the servicesmentioned. June 2016 update - a monthly meeting is inplace as part of the planned care programme to expand thismulti-disciplinary service, supported by GP's, sports andexercise medicine consultant, extended scopephysiotherapy, podiatry and exercise and weight lossprogrammes. A 3 month data analysis (Apr-June16) will beundertaken in July to review changes in referral flows.

R3 Apr-15 Welsh Government andHealth Boards should worktogether to reshape theorthopaedic outpatientsystem and improveperformance to a levelwhich, at a minimum,complies with WelshGovernment targets andreleases the potentialcapacity set out in Appendix4 of the report.

High Pathways for follow-up will be reviewed by theorthopaedic collaborative care group. DNA rates,length of stay and improving daycase rates arecovered in actions below.


InauguralmeetingOct 2015

Completed June 2016 Update - DNA rates are dependent on the roll-outof partial booking across the health board. DOSA and ALOShave both shown improvements in the past 6 months.

March 2016 Update - Work to date has focussed on newpatient pathway. Follow up pathway to be reviewed nextalongside data validation and implementation of the plannedcare programme arthroplasty follow up guidance.

R5 Apr-15 The Welsh Government andhealth boards should worktogether to undertake anevaluation of CMATS toprovide robust evidence asto whether they areproviding sustainablesolutions to managingorthopaedic demand.

High An initial audt and evaluation of CMAT'sphysiotherpay services in Cwm Taf was completedthis year on activity 2014-15 and an action plan toimplement improvements and standardise systemsacross the Health Board is being implemented. Areview of Triage meetings and process is ongoingand will be completed in October 2015 to inform a360 degree review of the service as a whole.


Oct-15 Completed March 2016 Update - Completed - revised triagearrangements in place from 1 April 2016.June 2016 - No further update as point 1 above.

R6 Apr-15 The Welsh Government andHealth Boards should worktogether to develop a suiteof outcome measures aspart of the OutcomesFramework, supported byrobust information systems,which providecomprehensive managementinformation as to whetherorthopaedic services aredemonstrating benefits topateints and minimisingavoiudable harm.

High This action will be taken forward as part of theNational Orthopaedic Planned Care Programme,and planned procurement of an all-Wales ITsolution to measure PROMS (Patient relatedoutcome measures).


In line withNationalProgramme

Summer 2016 Completed Sept 2016 update - PROMS pilot in Cwm Taf about to roll-outfor hips and knees only. Project manager appointed withinInformation team

March 16 update - Awaiting procurement of all-Walessolution. June 2016 Update - Pilot in AB and BCU duringsummer 2016, plan to roll-out at Cwm Taf in the autumn.

Comparative Picture of Orthopaedic Services (January 2017)

5

CPOS 01 Apr-15 Outpatient services:• The ratio of follow-up tonew appointments in theHealth Board is the secondhighest in Wales at 2.3 andabove the WelshGovernment target of 1.9.• DNA rates are above theWelsh Government targetsat 8.7 per cent of newappointments and 13 percent of follow-upappointments. The follow-upDNA rate is the highest inWales.• The patient cancellationrates are 5.7 per cent and10.7 per cent for new andfollow-up appointmentsrespectively.

High Follow up pathways are being reviewed as part ofthe Orthopaedic Planned care programme.Implementation of text and remind service isexpected to improve DNA rates. This will bemonitored and further action taken if Text &Remind does not generate the improvementanticipatedA detailed capacity and demand exercise has beenundertaken to confirm baseline numbers of clinicsand consistent templates.A revised process is in place to monitor cancellationof clinics outside of 6 weeks


Jun-15 Sep-16 In Progress March 2016 Update - work to date has focussed on newpatient pathway. Validation of follow ups is underway, withimplementation of the planned care programme arthroplastypathway planned in the next 6 months. June 2016 update -validation of follow-ups continue with the number of patientswaiting past target date reduced by 1000. Clinicalagreement needed to implement the recommendedarthroplasty follow-up pathway this is in progress.Sept 2016 Update - validation of follow-up patients waitingover target date continues, supported by additional clinics.Arthroplasty follow-up pathway agreed and in place.Jan 2017 - There is a need to evaluate the effect of the Text& Remind Service on DNA rates. Further action is also beingtaken to address Follow Ups Not Booked, including validationof long waiters. March 2017 - Further action is also beingtaken to address Follow Ups Not Booked, including validationof long waiters. Further validation of patients on the FUNBlist is being undertaken, consutlants are asked to look atclinic letters. August 2017 - Consultants are carrying outvirtual clinics in a bid to determine the patients who doactually require a follow up. Steady progress is being made.November 2017 update - Clinical & Non Clinical Validationcontinues and there is a stronger alignment with thenational planned care programme board. Jan 2018 update -Text reminders are having an impact on DNA rates. Partialbooking will be rolled out to all FUP appointments in2018/19. March 2018 update - still in progress

CPOS 03 Apr-15 Physiotherapy services:• Patients are not yet able toself-refer directly to thephysiotherapy service.

High There is currently a pilot underway for self- referralfor primary care MSK in Cynon Locality, with a planto evaluate and roll out if successful


Oct-15 Completed Update as at Jan 2017. Pilot outcome data favourable.Engagement sessions with all GP practices via clustermeetings has been undertaken to gain support for investmentand implementation of a new primary care MSKphysiotherapy model. The new model will not require a GPreferral but will be self referral into the service. Its hopefulthat following LMC approval in mid Feb 2017 that recruitmentcan be undertaken to launch the service in April / May 2017across the Health Board.

March 2016 Update - A self referral trial was piloted in theCynon Valley and modified to a same day service.Governance issues around the trial of self referral madecontinuation of this service unsustainable. Same dayreferral enables patients to ring on the day they have seentheir GP and be seen within 24 hours. This is far moreresponsive, robust and safe service. June 2016 Update - Nofurther update. Sept 2016 Update - There is currently a pilotunderway for same day service access for Physiotherapy inall localities within Cwm Taf for MSK. In both Rhondda andCynon a telephone triage service with a highly skilled Physiois being trialled to inform the further potential developmentof a self referral service into primary care MSK physioservices. This would potentially negate the need for a GPappointment and referral into primary care Physiotherapyfor MSK problems. Outcomes of the pilot are expected inNovember.

CPOS 05 Apr-15 Day case rates:• The percentage of therecommended orthopaedicprocedures undertaken as aday case is below the WelshGovernment target for bothPrince Charles and RoyalGlamorgan hospitals at 65and 70 per centrespectively.

High There is no day surgery unit at RGH, but plans arein place to address this in the next 2 years. In PCHthere is a capacity shortfall for day surgery theatrespace.A review of theatre space across both sites fororthopaedics is needed alongside sub-specialtylevel capacity planning. This work will be takenforward as part of the Orthopaedic Planned Careprogramme. In addition, the Directorate plan tocentralise urology flexi-cystoscopy procedures atRGH, which would provide additional day theatrespace for orthopaedics at PCH


N/A In Progress March 2016 Update - Increase in day theatre/day wardcapacity at RGH remains dependent on transfer of otherservices. Plans to centralise urology flexi-cystoscopy haveprogressed and this is expected to release further daysurgery capacity at PCH by the end of the summer 2016.June 2016 Update - The transfer of flexi-cystoscopy sessionsto the GUM unit at RGH is planned for October/November2016 and this will release day theatre space in PCH. Sept2016 - No further update. Jan 2017 update - fo furtherprogress made. Dependent on wider service changes e.g.ground and first floor scheme PCH. March 2017 - No furtherprogress made. August 2017, ongoing phased plans tomove Flexi cystoscopies from PCH to RGH, this includesequipment, staffing and a review of options to utilise thiscapacity overal are being developed. Currently delays infully commisioning the Treatment Centre and to plans toconvert PCH flexi lists to general anaesthetic lists. Centreopened 10 July 2017. Day case rates are being monitoredand will be discussed at CBMs and this will inlcude options toincrease the day case rate within current capacity.November 2017 Update - Work being undertaken withOrthopaedic Consultants to improve day of surgeryadmission. Pilot currently underway. Work across sceduledcare to identify cases that are in an inpatient setting that aremore appropratley placed in a day case environment.January 2018 - Orthopaedic day case rates have risen abovethe Welsh Goverment target . March 2018 update - still inprogress








Committee/Group





6

CPOS 06 Apr-15 Length of stay:• The proportion of patientsadmitted on the day ofsurgery is the lowest acrossWales at both Prince Charlesand Royal Glamorganhospitals.• Average length of stay foran elective orthopaedicpatient in the Health Boardis 4.5 days, which is outsidethe Welsh Governmenttarget of four days and thehighest across Wales.

High Following a pilot with the CD for Orthopaedics inautumn 2014 performance has improved from 30%- 65% at PCH, and up to72% at RGH (as at end of June 15). A roll-out planis in place to achieve 80% by the end of December2015. Recruitment of additional ANP posts tosupport this work are currently advertised.


Dec-15 Completed Jan 2017 Update - Posts in place as of January 2017 June 2016 Update - Failure to recruit to nurse practitionerposts has resulted in posts being readvertised. Day ofSurgery admission is agreed for all consultants and in place.Reasons for increased length of stay are variable, andinclude current configuration of beds. The surgicaldirectorate team with clinicians and nursing teams on bothhospital sites are developing an action plan as part of thescheduled care cross cutting theme.March 2016 Update - Unfortunatley bed pressures in recentmonths at both sites, and nursing staff shortages on theRGH site resulting in the need to close surgical capacity hashad an impact on performance. There are plans in place toreturn to DOSA for all surgeons as soon as possible,together with two orthopaedic nurse practitioner postsrecently advertised.June 2016 Update - Length of stay has reduced to 3.2 days.Sept 2016 update - DOSA and LOS performance ismonitored and improving. Successful ANP interviews willresult in 3 posts on each site from December 2016.

CPOS 07 Apr-15 Operating theatres:• Orthopaedic theatreutilisation ranges between80 and 93 per cent acrossthe Health Board. Thisremains below the WelshGovernment target of 95 percent.• The rates of cancelledoperations and cancelledtheatre sessions are bothhigh, with 34.7 per cent oflists cancelled at PrinceCharles Hospital.

High At PCH site the planned first floor redevelopmentwill enable a change in how the specialty managesits capacity with laminar flow and treatment roomoptions.This is linked to lack of theatre capacity highlightedabove and trauma/elective split ie. Patients arecancelled but replaced by trauma. The Directorateplan to provide additional day theatre space fororthopaedics at PCH by centralising Urology flexi-cystoscopies at RGH will help supportimprovements


Mar-16 In Progress March 2016 Update - As above.June 2016 - No further update. Sept 2016 - No furtherupdate.Jan 2017 update - no further progress made. Progress isdependent on wider service changes e.g. ground and firstfloor scheme PCH, which provides an opportunity to addresstheatre list allocation, particularly at PCH for elective, daycases and trauma. March 2017 Update - No further progressmade. November 2017 Update -Theatre utilisation is being discusssed at ACT and SurgeryRecovery meetings. Improved utilisation aroundproductivity is already being initiated in opthalmology. Latesatrts and early finishes are monitored through the newqliqsense app enabling CD's to interrogate the data byspeciality and inform actions. January 2018 - Work is nowunderway on improving theatre utilisation rates as part of aprogramme of work led by Deb Lewis, Assistant Director.This work will be reported to the productivity, Efficiency andValue Board. March 2018 Update - Still in progress

Follow Up Outpatients Not Booked (January 2017)R1 Jan-16 Ensure that there is

sufficient information on theclinical risks of delayedfollow-up outpatientappointments reported torelevant sub-committees sothat the Board can takeassurance from monitoringand scrutiny arrangements.

Medium/ Low Regular reports have been provided to the Finance,Performance & Workforce and the Quality andSafety Committees. These will continue with aspecific focus on those specialties where delaypresents a high risk. Extensive discussions havetaken place on how to identifiy and assess risksassociated with follow ups not booked withoutappointments and whilst some work has beenundertaken in reaction to reported sight loss inohpthalmology, limited progress made on thespecific. A directed audit will be considered forreporting to Q,S&R Committee early in 2018.


Mar-16 May-18 Completed September 2018 - The COO presented a proposal to theExecutive Board in July outlining the additional resourcingrequired to address the back log taking a risk based approachand outlining the project plan in place to strengthen anddevelop performance. For the first phase £200k was agreedand the first stage for ophthalmology has been instigated.Going forward full updates will be included within theIntegrated Performance Dashboard. The COO has presenteddetailed reports to the QSR in May and September 2018 andin January and March 2019. The FPW also had an update inMarch 2019

June 2018 Update - Report presented to the Quality, Safety& Risk Committee in May 2018. Position continues to bemonitored as the actions listed below are progressed.








Committee/Group





7

R1 FollowUp

Oct-17 Ensure that there issufficient information on theclinical risks of delayedfollow-up outpatientappointments reported torelevant sub-committees sothat the Board can takeassurance from monitoringand scrutiny arrangements.

Medium/ Low The original review in 2015 identified that theHealth Board needed to broaden the informationreported to the Board and is sub committees sothat it was aware not only of the volume of delaysbut also the clinical nature of delays in outpatientfollow-up appointments.Since our review the level of scrutiny and focus bythe Health Board has increased. There is a cleardrive to improve the follow-up position and detailedinformation is presented in terms of the currentperformance to Finance, performance andWorkforce committee. Quality, Safety and Riskcommittee has also been scrutinising theperformance of the Health Board.However, although the Health Board is targeting itsfocus on the highest volume areas of follow-upbacklog it has not yet produced a risk assessmentfor follow-up outpatients to determine the clinicalconditions where delayed appointments may resultin harm.A recent paper to the Quality, Safety and RiskCommittee did aim to provide assurance in relationto the clinical risks for patients on the follow-uplist, however it did not meet the needs of thecommittee, and independent members have askedthe team to revisit the paper and resubmit it. Thisis planned for September 2017.The Health Board utilises its Datix system toidentify any patients that have come to harm as aconsequence of delayed follow up appointments,and these mechanisms are utilised as required.However, despite the lack of a formal assessmentof clinical risk, it is clear that within the specialtiesthere is a focus on the clinical areas which cancause the most clinical harm, The Ophthalmologydepartment, for instance, is clear on the conditionswhich have the most potential for harm and istaking steps to minimise the risk to patients. Whereharm has been identified it is capturing this andreporting as required to Welsh Government.Work remains ongoing in this area, one area tonote however is the continued focus on the follow-up backlog from independent members and theexecutive management team. It is clear that this isa priority for the Health Board, and will remain anarea of focus.

In Progress January 2018 Update - A senior manager from the COOteam is providing focused senior support to improve theposition with an initial focus on gastroenterology. Work isunderway to support the clinical team to fully understandthe backlog position and to review the patients waiting thelongest through clinical nurse specialist reviews and virtualclinics initially. Discussion is also ongoing to refine the riskstratification plan in order to provide additional assurance inrespect of the management of any known clinical risks. July2019 update - FUNB work continues with a strong drive andfocus from COO and Deputy COO and Board level supportfor an ongoing resource plan of c. £1m. Full reports havebeen provided to FWP and QSR committees in the lastmeeting cycles confirming that the UHB is on trajectory forits intended end of year position of 10k patients on the list(currently about 13k patients on the FUNB list dropping fromc.19k patients following Ophthalmology cases outsourcing).Given this performance the Welsh Government hasresponded to our recent updates and welcomed a bid forperformance funding to see if our delivery of a balancedposition (due end of 20/21) could be accelerated. In termsof quality, we continue to report every case of harmgenerated by delays for clinical treatment through theregular FUNB report to QSR committee. Currently, the UHBhas the most advanced FUNB position in Wales.

R2 Jan-16 Ensure compliance withrevised administrative andbooking processes acrossthe organisation to avoidunnecessary retrospectivevalidation of patient records.

Medium/ Low Regular compliance reports will be monitored at theRTTmeetings and Scheduled Care Board, attendedby all the appropriate directorate managers.Immediate corrective action will be put in placewhen necessary to avoid retrospective validation.


Apr-16 In progress Sept 2016 Update - Regular compliance reports are beingmonitored at the RTT meetings and Sceduled Care Board.Jan 17 - The complaince reports have highlighted thatadherence to the agreed administrative and bookingprocesses is still not being followed in some areas. Details ofthe staff who are non compliant is available to thedirectorate managers in order to implement correctiveactions. March 2018 Update - Work continues to improve inthis area. As part of the outpatient improvement theme newsoftware has been introduced for clinicians to enable themto record the outcomes of their consultations in real time.Although only rolled out to a small selection of specialitiesthe system has potential to improve recording of patientoutcomes which will support the quality of patient data inrespect of follow-ups. Performance data is also capturedthough the Qlik Sense system. This data analytics toolenables directorates and clinicians to interrogate a vastarray of data to support day to day management andcontinuous improvement. September 2018 - The COOpresented a proposal to the Executive Board in July outliningthe additional resourcing required to address the back logtaking a risk based approach and outlining the project planin place to strengthen and develop performance. For thefirst phase £200k was agreed and the first stage forophthalmology has been instigated. Going forward fullupdates will be included within the Integrated PerformanceDashboard. December 2018 update - Much work has beenundertaken to cleanse all areas of the waiting lists to ensureno patients are lost to follow up. This has had a negativeimpact on the FUNB numbers as patients are transferredonto the FUNB lists from other areas of the waiting list. TheICT and medical records team are undertaking training forall staff who fail to outcome appointments appropriately andfurther work will be undertaken with the outpatient staff.This is an area that will require continous monitoring andaction over the forthcoming months. March 2019 In general,positive progress has been made with ensuring revisedbooking processes are consistently applied across the healthboard. The planned care programme board hascommissioned and completed a project workstream onimproving administration and booking processes which hasdemonstrated positive improvement and the work will bewithin scope of the recently commissioned internal audit tolok at data quality pathway management.








Committee/Group





8

R2 FollowUp

Oct-17 Ensure compliance withrevised administrative andbooking processes acrossthe organisation to avoidunnecessary retrospectivevalidation of patient records.

Medium/ Low The original review reported that the Health Boardwas undertaking unnecessary retrospectivevalidation activities and this was an additionalpressure on capacity which could be avoided.Unfortunately retrospective validation is still beingundertaken by the Health Board. The latest figuresreported in April 2017 show that the currentvolumes of patients without a target date was1,129, however this is a significant improvementfrom the same time last year where the volumewas 3,509. It remains an area of focus for theHealth Board.Work continues to improve in this area. As part ofthe outpatient improvement theme new softwarehas been introduced for clinicians to enable them torecord the outcomes of their consultations in realtime. Although only rolled out to a small selectionof specialities the system has potential to improverecording of patient outcomes which will supportthe quality of patient data in respect of follow-ups.Performance data is also captured though the QlikSense system. This data analytics tool enablesdirectorates and clinicians to interrogate a vastarray of data to support day to day managementand continuous improvement.


In Progress

R3 Jan-16 Evaluate service changesadopted by the Health Boardto address delayed follow-ups so that impact can bemonitored and timelyintervention taken if impactsare not being achieved asexpected.

Medium/ Low An evaluation of the impact of service changes tobe undertaken and reported back to theOutpatients Cross Cutting Theme.


Jun-16 Completed June 2018 update - A plan is being developed to address theexisting backlog on a specialty basis. The programme ofwork will take 2-3 years and will need to be resourcedappropriately. Once the backlog has been reviewed andaddressed and sustainable processes and monitoringarrangements are established, the position should bemanaged within existing demand and capacity plans.

June 2016 Update - Monitoring of impact of service cnangeson delayed follow-ups to be reported via Clinical Businessmeetings and through delivery of Directorate D&C plans aspart of specific actions to address backlog. OutpatientImprovement Cross Cutting Theme is looking at reducingfollow up rates. Sept 2016 - No further update.Jan -17 Update - The outstanding follow up backlogs havebeen incorporated in their 2017/18 demand and capacityplans for each of the specialties. Improvement trajectorieshave been developed for each of the service changesproposed and these will be monitored through themechanisms described above. March 2017 Update - Nofurther progress made.

R3 FollowUp

Oct-17 Evaluate service changesadopted by the Health Boardto address delayed follow-ups so that impact can bemonitored and timelyintervention taken if impactsare not being achieved asexpected.

Medium/ Low Our original review looked at the work of the HealthBoard in modernising outpatient services. Wereported the Health Board was putting in placeshort term operational arrangements as well as alonger term approach to modernising outpatientservices.There remains focus by the Health Board onoutpatient improvement. The outpatientimprovement theme has been subsumed into theplanned care theme and the delivery mechanismfor this is the Scheduled Care Group. Anotherrecent appointment is an associate medical directorwith responsibility for Productivity, who will besupporting the directorates.In conjunction with this, specialities haveundertaken a range of activities to address thedemand for follow-up outpatients. Performance ofthese activities is monitored through the localdemand and capacity plans. However, there hasyet to be a fundamental evaluation which bringstogether the service changes implemented


Jun-16 Completed January 2018 Update - Complete








Committee/Group





9

R4 Jan-16 Develop operationalarrangements to deal withthe backlog in delayed follow-up appointments, inparticular, those specialitiesor clinical conditions wherethere is likely to be harm topatients who are delayed.

Medium/ Low Where specialities are identified to have a backlogthrough the previously described monitoringmechanism, resources will be identified with thedirectorates to address these. Resources will bedirected initially at those specialites where the riskof harm is greatest


Mar-16 In progress Sept 2016 Update - Follow up backlogs have beenincorporated in their 2016/17 demand and capacity plans foreach of the specialties. Directorates have developed plans toprovide the additional capacity with changes to clinictemplates, additional sessions and the creation of virtualclinics. Improvement trajectories have been developed andthese will be monitored through the mechanisms describedabove. Jan -17 Update - Following a report to theFinance Performance and Workforce Committee on progress,the Committee have requested that directorates focus onthe top 10 specialties i.e. those with the largest number ofpatients past their target date where ongoing delay has anincreased potential to result in harm. The specialies areOphthalmology, ENT, General Medicine, Orthopaedics,Gastroenterology, Gynaecology, Urology, Rheumatology,CAMHS and Respiratory Medicine. An update to the Finace,Performance & Workfroce Committee in May 2017demonstrating improvement has been requested. March2017 Update - No further progress made. June 2018update - A plan is being developed to address the existingbacklog on a specialty basis. The programme of work willtake 2-3 years and will need to be resourced appropriately.Once the backlog has been reviewed and addressed andsustainable processes and monitoring arrangements areestablished, the position should be managed within existingdemand and capacity plans. September 2018 - The COOpresented a proposal to the Executive Board in July outliningthe additional resourcing required to address the back logtaking a risk based approach and outlining the project planin place to strengthen and develop performance. For thefirst phase £200k was agreed and the first stage forophthalmology has been instigated. Going forward fullupdates will be included within the Integrated PerformanceDashboard. December 2018 update - Plans are developingin all specialities with some areas making more progressthan others. In the main the areas with smaller numbers ofFUNB are making greater progress. Ophthalmology remainsan area of concern as there is limited confidence in the planto date due to Consultant chnages abd reliance on otherprofessionals to undertake the required backlog work. Themain limiting factor is availability of clinicians to undertakethis work as additional sessions. The COO has presenteda detailed report to the QSR in May and Sept 2018 andJanuary and March 2019. The FP&W committee alsoreceived a full report in March. The UHB has made goodprogress on working through the backlog of FUNB patientsthrough a project board across a range of specialties and theQSR reports are being used to identify and clinical risks on acase by case basis. Risks have been identified and mitigatedin gastroenterology and in the last cycle the same processhas been applied in urology and oral surgery services. Mosturgently the UHB has prioritised £500k on top of last year's£200k of end of year spend towards ophthalmologyoutsourcing to ensure that FUNBs are reduced in an area ofhigh clinical risk. The UHB has included comprehensivetrajectories in the integrated dashboard and IMTP to followthroughout the next 2 years and there is a positive trendcurrently being reported.

R4 FollowUp

Oct-17 Develop operationalarrangements to deal withthe backlog in delayed follow-up appointments, inparticular, those specialitiesor clinical conditions wherethere is likely to be harm topatients who are delayed.

Medium/ Low Our review in 2015 concluded that although theHealth Board has plans to develop services withinthe community, current operational arrangementswere having a limited impact on reducing delayedfollow-ups and service modernisation would bechallenging.Within specialities and directorates there are arange of activities in place to maximise the capacityof the Health Board. We were signposted to newways of working, for example within Respiratorywhere a specialist nurse is triaging referrals toidentify where patients could be seen by a nurseinstead of a consultant, therefore freeing upcapacity. Within the Ophthalmology department,community optometrists are being used to providefollow-ups and additional capacity. The range ofactivities is promising, and shows the commitmentof staff within the services to maximise theirefficiency. The success of these initiatives ismonitored through the regular performancemonitoring arrangements in place, and feeds intothe demand and capacity plans owned by theservices. However, despite these examples of goodarrangements there has been less attention givento transformational change to outpatient models.This is recognised within the Health Board, andthere is recognition that new ways of working needto be explored and a focus on whole systemschange, looking at referral management through topatient discharge


Mar-16 In Progress January 2018 update - A senior manager from the COOteam is providing focused senior support to improve theposition with an initial focus on gastroenterology. Work inunderway to support the clinical team to fully understandthe backlog position and to review the patients waiting thelongest through clinical nurse specialist reviews and virtualclinics initially. Discussion is also ongoing to refine the riskstratification plan in order to provide additional assurance inrespect of the management of any known clinical risks. April2018 Update - A senior manager from the COO team isproviding focused senior support to improve the positionwithin a number of key specialties with an initial focus ongastroenterology. Work is underway to support the clinicalteam to fully understand the backlog position and to reviewthe patients waiting the longest through clinical nursespecialist reviews and virtual clinics initially. Discussions todate have been held with the clinical leads forgastroenterology, cardiology, orthopaedics, ENT surgery andophthalmology. 70+ patients have been reviewed ingastroenterology and plans are in place for monthly virtualreview clinics. Some clinical risk has been identified andwhilst the majority of the patients have been discharged anumber will require follow up appointments. An extraoutpatient clinic is planned for May to pick up a furthercohort of the gastroenterology patients. Discussion is alsoongoing to refine the risk stratification plan for eachspeciality in order to provide additional assurance in respectof the management of any known clinical risks. It is clearthat a dedicated resource is needed in order to progress thework with each of the specialities and attempts are beingmade to secure an additional administrative resource.

R5 Jan-16 Profile follow-up reductionsin order that the HealthBoard can monitor theprogress and impact ofoperational arrangements.

Medium/ Low This has already been implemented. Reports areproduced weekly and are available at anoperational level via the SharePoint site. Monthlyupdates are included within the IntegratedPerformance Report as well as being presented ona quarterly basis to the Finance, Performance andWorkforce Committee.

Director ofPlanning &Performance

May-15 Completed June 2018 update - Trackers are being developed to monitorthe position in each specialty on a weekly basis. Dec 2018update - FUNB dashboard is now accessible to all relevantstaff. There has been significant progress made by medicalrecords and ICT staff to rationalise all waiting lists to ensureno patients are lost to follow up. This has had a negativeimpact on the FUNB numbers. Development of a robusttrajectory for the reduction of FUNB in the future is difficultto determine at this stage until all associated work onwaiting lists is completed. The development of a trajectoryof improvement is highly reliant of clinical staff identifyingextra sessions within their working week which is alsofragmented and unpredictable.








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10

R5 FollowUp

Oct-17 Profile follow-up reductionsin order that the HealthBoard can monitor theprogress and impact ofoperational arrangements.

Medium/ Low Individual directorate demand and capacity plansare in place. These break down to a sub specialitylevel. These clearly outline the capacity within thedirectorate and make a clear link between thecapacity, additional resources and new ways ofworking. Directorates are monitoring theirtrajectory performance weekly, and ensuring theyare meeting their profiles as set out in the demandand capacity plans. The plans are constantlyrevisited to ensure they remain current. Within allareas there is awareness of these demand andcapacity plans and within booking teams anyalterations to clinic templates have to be agreedwith directorates to ensure that any impact on thedemand and capacity plans is understood andaccounted for.This work is further strengthened by goodperformance monitoring systems (Qlik Sense)which enable timely monitoring down to consultantlevel. These arrangements continue to be refinedby the Health Board.


May-15 Completed

Information Management and Technology Audits (January 2017)R1 Jan-16 Develop business continuity

plans in line with thestandard set in thecorporate template businesscontinuity plan for the keyclinical departmentsindicated in Exhibit 1 (of theoriginal report, which wereRadiology, ITU, Pharmacy,Pathology, A&E, Theatres,ICT) and ensure such plansexist for all other clinical andnon-clinical departments.

Medium/ Low The business continuity plans are with theindividual departments and are being compiled withcoordination and input from Richard Sealey, CivilContingencies Manager. 17 BC plans are already inplace covering all core functions. The one exception- a specific A&E plan (currently covered under theMedicine BC plan) will be developed by thedepartment with support from the CivilContingencies Manager Sept update RS - the UHBnow has 20 in date BC plans (up from 17) allreviewed in 2016. Only ICT and Vaccination areoutstanding and are being worked on by Depts.

Director ofCorporateGovernance

Jun-16 Completed Jan 17 update - the HB has 18 BC plans all in date with theImmunisation andVaccination Coordinator Service plan currently out for review

R2 Jan-16 Develop, approve at seniorlevel and regularly review abusiness continuity plan forthe ICT department, basedon a comprehensive riskassessment and the HealthBoard’s template businesscontinuity plan. This shouldinclude all risks affecting thedepartment’s ability toprovide continued supportfor the Health Boards ICTinfrastructure and systems,including staffing levels.

Medium/ Low There is a business continuity plan developed forICT but it does not cover all the recommendationsin the Audit. It will require review to meet all thepoints detailed.


May-16 Completed January 2017 update - updated BCP for ICT received by CivilContingencies Manager

June 2016 Update - The ICT Business Continuity Plan hasrecenty been reviewed in line with the auditrecommendations. The plan will be updated shortly,reflecting these recommendations. Sept update progressmade by ICT but currently being reviewed.

R3 Jan-16 Introduce arrangements toconsider cross departmentand site level businesscontinuity issues.

Medium/ Low The ability to work cross site will require the Healthboard leads in each department who areresponsible for the business continuity plans towork with ICT on the feasibility for the IT system towork in this manner. This will also require capitalinvestment. Cross site level BC already existswithin the Radiology Directorate. A site level BCEvacuation plan has also been developed andtested with a tabletop exercise by the CivilContingencies Manager for YCC. This will now beconsidered for other sites.


May-16 Completed Jan 17 update - Radiology have confirmed that they havecross site and site level BCPs. SIte level BC is picked upthrough the COO escallation plans and Winter plan

June 2016 Update - From an ICT perspective clinicalsystems have been set up in a way which enables cross siteaccess from any terminal within the Health Board. Wherededicated workstations are required, for example PACS,then these types of devices are strategically distributedaround the Health Board to enable continuity of the service,as far as practically and affordably possible. Sept update RS- Evacuation is being developed with the new suspectpackage / bomb threat procedure. Discussions have alsotaken place to further develop the Radioliogy BCP andinclude scanner BCPs.

R4 Jan-16 Test business continuityplans regularly to ensurethey operate as intendedand adequately supportcontinued clinical serviceprovision within and acrossdepartments.

Medium/ Low This will be the responsibility of each individualdepartment to test their business continuity plan –Corporate support will be provided to take forwardthis action. ICT will be required to ensure their planis in place and tested.


June 2016/September2016

Completed Jan 2017 Update - Pathology BCP tested live and only minorchanges required as seen as fit for purpose. BusinessContinuity of RGH server and telecoms site issues tested May2016

June 2016 Update - As indicated in the comment below ICTare required to ensure that their plan is in place and tested.This is being addressed in No R2. Sept update RS - ICT plannow out of date and Chris Ball asked to progress review.Also need to ensure as part of the review that bcp testingwill also take place.

R5 Jan-16 Identify from testing of thebusiness continuity plansand manual procedures theeffect on quality, cost andtimeliness of clinical serviceprovision of utilising manualprocesses to inform futurecontinuity planning.

Medium/ Low This will be the responsibility of each individualdepartment. Corporate support will be provided totake forward this action.


Sep-16 Completed Jan 2017 Update - Pathology BCP tested live and only minorchanges required as seen as fit for purpose. BusinessContinuity of RGH server and telecoms site issues tested May2016, in response to live incident and amendments made asa consequence.








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11

R6 Jan-16 Reinforce businesscontinuity governancearrangements bycommunication and trainingfor relevant managers,clinicians and other staff andensure that there is a clearunderstanding of thedifference between businesscontinuity and disasterrecovery planning.

Medium/ Low This will be the responsibility of each individualdepartment with corporate support provided


Sep-16 Completed Jan 17 update - all BC plans uploaded onto new Diligentpaperless system so that all Execs have access to alldocuments on their iPads when on-call out-of-hours, alsoused this approach to strengrhen Intranet access to relevantmaterial.

R7 Jan-16 Establish formalarrangements to reviewbusiness continuity plansand risk assessments toensure they arecomprehensive, consistentand appropriate for businessneed.

Medium/ Low This will be the responsibility of each individualdepartment. However, the Civil ContingenciesManager will have a role in coordinating andsupporting the clinical directorates with this action.Sept update RS - we have been movingdepartments to use the standard template forconsistency with limited sucess.


Sep-16 Completed Jan 17 update - all BC plans requiring review coordinated byCilvil Contingencies Manager and all revewed by Departmentsin 2016 and updated. Curently looking at merging BCP and on-call handbook to make one document

R8 Jan-16 Improve the current ICTdisaster recovery plans foreach of the systemsreviewed, for other keysystems and for the ICTinfrastructure to ensure theyare adequate and meet thefollowing minimumrequirements:• plans should bedocumented and written in asimple language, so they areunderstandable to all whomay need to use them;• responsibilities for thedisaster recovery plansshould be clearly identified;• there should be a clearidentification of personsresponsible for each functionwithin the plan;• contact information shouldbe clearly identifiable;• plans should include a step-by-step explanation of thesystem recovery option;• the various resourcesrequired for recovery shouldbe clearly identified;• plans should be approvedby an appropriate manager;and• plans should be updatedand reviewed regularly withreview and version controlclearly stated on the front ofeach plan.

Medium/ Low There are 7 disaster recovery plans for keysystems. To ensure the disaster recovery plans arereviewed and meet all the points identified therewill be a requirement to work with NWIS andcommercial companies for those managed services.

Director ofFinance

Jul-16 Completed March 2017 Update - BCP continue to be developed andtested in the service areas noted.

June 2016 Update - Karen is reviewing these DisasterRecovery Plans with her Clinical staff in-line with the auditrecommendations and these should be completed by the endof July.

R9 Jan-16 Test all ICT disasterrecovery plans for thesystems and infrastructureregularly to ensure theyoperate as intended.

Medium/ Low To test all systems there will need to beconsiderable capital funding to provide back upservers and staffing levels. This will need to beidentified as a capital funding bid.

Director ofFinance

Sep-16 Completed Apr 18 Completed with ongoing development work as newinfrastrucute is introduced.

June 2016 Update - Some of the Disaster Recovery Plansrelate to national systems, and the recording of these testswill be picked up in the review of these plans as indicated inR8. With reference to local systems then the ability to testthese Disaster Recovery Plans are restricted to availability ofadditional equipment, which is subject to capital fundingrequirements (as indicated below).Jan 2017 update - no change to the update position aroundlocal plans an capital funding. March 2017Update - Continuing to make steady progress, in view of thelimited funding and late timescales of the capitalprogramme, and the disruption that testing causes.However, several limited failover tests have beendemonstrated, e.g. Exchange email system can now befailed over, as of the last few weeks. Aug 2017: continue torationalise the server estate and systems, to improve theability to failover systems to other servers and/or othersites. Also, improvements to the Cwm Taf infrastructuremean that the likelihood of disruption is minimised. Anumber of clinical and admin systems are now externallyhosted, either by NWIS or outside of NHS Wales. Finally, itis unrealistic to test all plans for all systems, so a prioritisedapproach has been adopted.








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12

R10 Jan-16 Establish and monitor clearperformance indicators forthe ICT department,systems and infrastructure.Use the results of thisperformance monitoring toinform disaster recoveryplanning, ICT resourceplanning and ICTinfrastructure and systemcapital planning.

Medium/ Low This will be part of the development of the ICTstrategy.

Director ofFinance

May-16 Mar-17 Completed Aug 2017: ICT strategy and SOP have been submitted toWG, following approval by Exec board.

Jan 2017 Update - A contract was awarded to ATOS tocomplete the ICT strategy and develop the SOP. This is dueto be completed March 2017, following this it will requirepresenting to Executive Board.

R1 (newrecord)

Jan-16 Update the businesscontinuity policy andsupporting templates to:a) reflect current relevantguidelines and legislation;b) recommend that plansare reviewed and updatedregularly to reflectoperational changes;c) ensure that arrangementsrelating to cross departmentand site level businesscontinuity issues areconsider when plans aredeveloped and updated; andd) sufficiently explain thegovernance structure ofbusiness continuity anddisaster recovery, and howthe Health Board specificallyacquires assurance thatpolicy requirements are met.

Medium/ Low The ICT business continuity plan is in place butneeds reviewing to ensure it meets all the pointsdetailed below.Each individual department will be required toensure their plans are in place.

Director ofFinance

May-16 Completed June 2016 Update - This point is being addressed in R2.

R2 (newrecord)

Jan-16 Develop and agree a backuppolicy to ensure consistentbackup procedures,approaches and practicesare adopted across theorganisation.

Medium/ Low Back up policy in place for health board systems.Will need to incorporate the commercial and NWISmanaged systems into the health board review.Review will be undertaken to ensure all points aremet.

Director ofFinance

Jul-16 Sep-17 Completed Aug 2017: policy has been developed and will be submittedto the IG group in Sep 2017. Assuming sign-off at IG, thisaction can be closed.

June 2016 Update - The first draft of an overarching BackupPolicy has been developed. This will be required to bereviewed and agreed by Senior ICT Management beforebeing presented at the relevant board for approval. Jan2017 Update - no further progress made.March 2017 Update - Significant progress against thisrequirement, with policy nearing completion. A capitalinvestment in replacement backup system is currentlyunderway, and will allow further progress to be made.Additionally, investment in one of the server roles is allowingthis particular action to be further prioritised andprogressed.

R3 (newrecord)

Jan-16 Document and makeavailable (to appropriatemembers of staff)procedures for: a)creating and amending databackups, includinginformation on how toamend the system settingfor automated backups; andb) dealing with backupfailures or issues.

Medium/ Low This will be covered by the review above. The issueof restoring and testing back ups will need to beassessed with regards to available hardware anddisaster recovery systems being in place.Data relating to Myrddin is automatically backed upon the national update through the Blaenavon datacentre and there is no internal issue with this

Director ofFinance

Jul-16 Completed Aug 2017: staff are trained internally on backup procedures.This action can be closed.

June 2016 Update - This is being addressed as part of R2(new reco). March 2017 Update - The process forperforming restores of files has been shared withappropriate staff, and tested a number of times as a resultof cyber security attacks that have successfully deployedtheir payload.

R4 (newrecord)

Jan-16 Ensure that the ‘ServerBackup and RestoreDocumentation’ referred toin the DR plans exists andmeets the needs of the ITsystems.

Medium/ Low Will be included in the review of the serversdocumentation stated above. June 2016 Update -This is being addressed as part of R2 (new reco).

Director ofFinance

Jul-16 Completed Aug 2017: the documentation has been written and theaction can be closed.

March 2017 Update - Continues to be developed, particularlyin view of the capital investment noted. Documentation willbe shared as appropriate, and will be included in theInfrastructure on-call documentation as appropriate.

R5 (newrecord)

Jan-16 Ensure that the CaldicottPrinciples Handout is up todate and accurately refers tothe Caldicott Guardian sothat there is nomisunderstanding amongststaff.

Medium/ Low Caldicott principles page on SharePoint is updatedwhich includes the name of the Guardian.The principles handout has been updated but caninclude the name of the Guardian


Jan-16 Completed

R6 (newrecord)

Jan-16 Ensure that appropriate staffundertake relevant Caldicotttraining and maintain theirknowledge by regularrefresher training. Thisshould be monitored by andreported to the InformationGovernance Group.

Medium/ Low All appropriate deputies for the Caldicott guardianhave received specialist training which is monitoredthrough the IG Group.


Mar-16 Completed June 2016 Update - Caldicott approvals procedure documentin development.For all other staff the Core Skills Training Framework includesIG which will be monitored via CBMs and is recorded centrallyon ESR.The levels of training is also reported to IG Group.

R7 (newrecord)

Jan-16 Include data qualitycomparisons againstprevious years in futureannual data quality reports.

Medium/ Low Annual data quality report produced. Individualaudit already monitor the compliance and trendsyear on year

Director ofPlanning &

Performance

Ongoing Completed








Committee/Group





13

R8 (newrecord)

Jan-16 Ensure that the informationasset owners are namedindividuals who are aware oftheir responsibilities, whichif allocated by post, shouldbe written into their jobdescriptions.

Medium/ Low The major clinical systems have IG asset but willneed reviewing with the IG lead to ensure thecorrect individual has been identified. There is aquery as to whether it is the named individual orthe named post.


May-16 Completed Jan 2017 Update - All major systems now have IG assestssheets working on minor ones.

June 2016 Update - Karen Winder has forwarded informationrelating to key systems on to Information Governance forreview. Update from Claire Parsons - Action plan for thedevelopment of information asset register is in progress,with a completion timescale of September 2017. Assetowners to be identified as part of the data collectionexercise.

R9 (newrecord)

Jan-16 Ensure that the Data QualityPolicy is reviewed andregularly updated to reflectany changes in operationalarrangements. Apply versioncontrol arrangements toensure that there is clarityabout the current version. Inaddition, change the policy’swording to reflect theinformation governancegroup.

Medium/ Low Policy due for review which will be approved at thenext Corporate Risk Committee


Mar-16 Completed

R10 (newrecord)

Jan-16 Develop and agree an ICTStrategy.

Medium/ Low The scoping document has been produced with thestrategy being delivered by March 31st 2016.

Director ofFinance

Jun-16 Completed Aug 2017: action complete, see R10. June 2016 Update - This relates to the action in R10. Sept16 update - Strategy Developed in Draft, pending Executivediscussions. Jan 2017 update - A contract was awarded toATOS to complete the ICT Strategy and develop the SOP.This is due to be completed March 2017, following this it willrequire to be presented to Exec Board. March 2017 Update- The strategy will be delivered soon.

R11 (newrecord)

Jan-16 The Health Board shouldensure that ICTrecommendations form partof its Wales Audit Officerecommendation trackerthat is reported to AuditCommittee.

Medium/ Low The Audit Tracker developed in 2015 from 2014audit activity is being reviewed to consider anyoutstanding audit recommendations that pre-date2014.


Apr-16 Completed

Structured Assessment 2015 (January 2017)R1 2015 Jan-16 Whilst this is an ongoing

process the Health Boardneeds to ensure that:a. current 2015-16 savingsplans are signed off; andb. 2016-17 directoratesavings plans are signed offprior to the start of thefinancial year.

Medium/ Low a. Virtually all 2015/16 budgets are now signed off,with no material outstanding issues. Theoutstanding formal signatures will be obtained. b.All efforts will be made to get signed off directoratebudgets prior to the start of the financial year.Directorates will be supported to identify plannedsavings which meet savings targets set, but theseare unlikely to reach 100% of target prior to thestart of the financial year.

Director ofFinance

Jan-16 Completed a - Update as at Sept 2016 - Its important to correlateDirectorate IMTP's, related budgets and required savingstargets. Directorate savings targets are agreed on a moretimely basis with savings plans in place and signed off bydirectorates. B - Update as at Sept 2016 - Learning fromlast year's experience. Related processes were tightened toensure earlier agreement and sign off with regardsDirectorate savings targets, progress against which waspresented to F,P&W Committee.

R2 2015 Jan-16 The Health Board shouldsimplify its Monthly Financeupdates.

Medium/ Low The format of monthly reporting will be refreshedfor 2016/17, as it was for 2015/16. Engagementwill take place with the Board and with Directorateand other managers to ensure that the report andits key messages are well understood.

Director ofFinance

Mar-16 Completed Update as at Sept 2016 - The format of finance reporting toBoard has been amended to ensure clarity on updatespresented. High level reports have been developed for theHealth Board meeting, which have been positively received.A more detailed report is available for Executive Board. Thiscontinues to be a standard agenda item at Board level.

R3 2015 Jan-16 Ensure that IMTP progressreporting:a. incorporates progressagainst the stated in-yearpriorities; andb. clearly identifies progressagainst what the Board hadplanned to achieve at thatpoint in time.

Medium/ Low a. The quarterly reporting process, which ismaturing, will be reviewed to better reflect thisachievement against in-year stated priorities. b.The quarterly reporting process, which is maturing,will be reviewed to better reflect progress againstplanned achievements.


Oct-16 Completed a - Update as at Sept 2016 - The UHB continues to developand strengthen its quarterly reporting arrangements onprogress with implementation of the IMTP and in doing sotakes into account related WG guidance. Need also to crossreference with IMTP survey response b - Update as at Sept2016 - The UHB recognises the need to further strengthenreporting against planned intentions and is continuing todevelop its reporting arrangements (in the absence of specificWG guidance) to do so.

R4 2015 Jan-16 Map performance measuresto the Board AssuranceFramework to ensure thatthere are no gaps inassurance.

Medium/ Low The Board’s current assurance arrangements mapkey performance measures to Finance,Performance & Workforce Committee (R7). Anagreed performance management framework(which is under development and in draft) maynegate the need for this additional mapping.The framework also serves to inform the Board onthe principal risks threatening the delivery of itsobjectives, and aims to align its principal risks, keycontrols, its risk appetite and assurances alongsideeach objective. Gaps are identified where keycontrols and assurances are insufficient to mitigatethe risk of non-¬delivery of objectives. Thisenables the Board to develop and monitor actionplans intended to close any assurance gaps.


Sep-16 Completed Update as at August 2017 - Performance ManagementFramework signed off at Executive Board; implementationnow underway.

Update as at Sept 2016 - The Health Board’s BoardAssurance Framework is established and maturing and isbeing considered and reviewed by the Audit Committee andIntegrated Governance Committee.The revised Framework aligns more closely to the Board’sstrategic goals/objectives outlined within its 3 YearIntegrated Medium Term Plan (IMTP).

R5 2015 Jan-16 Review website content inrelation to key corporatedocuments and plans toensure that current versionsare clearly sign-posted toimprove accessibility bymembers of the public.

Medium/ Low The UHB is taking forward a review of its InternetSite and has developed plans to improve it.Accessibility to key UHB documents will beprioritised within these proposals.


Jun-16 Completed Update as at Sept 2016 - The UHB has from 1 August 2016,internally launched phase 1 of its new internet website, withrelated content management being updated. However, aspart of the requirements of the Publication Scheme, all keycorporate documents / policies etc will be available and moreeasily accessible on the website.








Committee/Group





14

R6 2015 Jan-16 Develop and embed forwardwork programming in all sub-committees and groups thatsupport the Board

Medium/ Low Good progress has been made during 2015/16 todevelop forward work programmes at subCommittee level. This will be completed in early2016 for all Sub-Committees.


Apr-16 Completed Update as at Sept 2016 - All sub committees of the Board(except Audit Committee, which has a structured agenda plansupported by an annual internal and external auditprogramme) have forward work programmes which arereviewed and updated prior to each committee. This is usedto agenda plan all meetings and ensure continuity of reviewperiods / policies etc.

R7 2015 Jan-16 Develop and adopt aPerformance ManagementFramework to enhanceaccountabilityarrangements.

Medium/ Low The Director of Planning and Performance will co-ordinate the development of an appropriatePerformance Management Framework with HealthBoard colleagues.


Sep-16 Completed Update as at Jan 2017 - The approval and implementation ofthe 'Draft' Framework has been delayed as a consequence ofits alignment with the revised Organisational ManagementStructure, where implementation commenced from January2017, following a period of engagement and consultation.

Update June 2016 - Framework drafted and currentlyundergoing engagement. Update as at Sept 2016 - APerformance Management Framework has been developed in‘draft’ and is being consulted / engaged upon in line with thecurrent UHB Organisational Change Programme. It isanticipated that this will be finalised and approved over thenext 3 months.

R8 2015 Jan-16 Develop succession planningfor the existing cohort ofIndependent Members anddevelop inductionarrangements in anticipationof terms of office ending.

Medium/ Low The recruitment of Independent Members is amatter for the Welsh Government PublicAppointments process and the UHB will continue towork with them in order to ensure appropriatesuccession planning. In relation to IndependentMembers a combination of National and LocalInduction arrangements will be made available.


2016/17 Completed Update as at Sept 2016 - The Health Board will continue towork with WG as these appointments are part of the publicappointments process. Local arrangements have been put inplace to ensure continuity for the Board when members termsof service is due to end.

More work is needed from the centre to develop independentmember induction arrangements. Pending the developmentof a more structured national approach, local inductionarrangements are led by the Chairman of the UHB, supportedby the Board Secretary and are tailored to respond to theneeds of individual Board Members.

In light of the anticipated change with the Chair and a largenumber of IMs changing over the next 12 months, BoardDevelopment discussions in terms of the collective Board, aretaking place with the Chair, CEO and Director of W&OD forfurther consideration by the Board.

June 2016 Update from Director of WOD - we participated inthe national programme to allow prospective candidates toshadow and be mentored by current NOMs. We havesuccessfully recruited three NOMS to replace three who haveleft in past six months and these are currently beinginducted. We will have further turnover of five NOMS overthe next 12 months and are actively developing aprogramme of activity to ensure we have suitableapplicants.

R9 2015 Jan-16 Put in place arrangements toachieve a uniform level ofoperational practice acrossall committees in terms ofchairmanship and scrutiny.

Medium/ Low Agreed house style/local arrangements in place toguide and support the work of Committee Chairsand IMs, it is recognised that individual experiencewill influence delivery. Such arrangements willneed to be informed by local and nationalinduction.


2016/17 Completed Update as at Sept 2016 - There are robust arrangements inplace to support the work of Committee Chairs andIndependent members. A more proactive agenda planningand Chair briefing has been established and the Chairman (aspart of his annual appraisal and monitoring processes)discusses this with IMs.

The UHB intends utilising one of its Board Developmentsessions to facilitate a session on the role of a committeechair and its IMs. Its likely that this will be more impactingwhen IMs turnover.

R10 Jan-16 Consider whether that as aminimum at least oneIndependent Member of theAudit Committee has recentrelevant financialexperience. If this is not thecase the Health Boardshould consider otherarrangements, such asappointing an associate nonexecutive with that relevantexperience.

Medium/ Low The Health Board is reviewing the membership ofthe Audit Committee, in light of anticipatedIndependent Member changes and will take thisrecommendation into account. Mr John Hill-Tout(Finance IM) is re-joining the Committee.


Apr-16 Completed Update as at September 2016 - Terms ofReference/membership for sub committees of the Board arereviewed on an annual basis, unless further change requiresearlier consideration. The Independent Member (Finance)lead is currently a member of the Audit Committee.

R11 2015 Jan-16 Develop a mechanism toensure that WAOrecommendations thatpredate January 2014 andwhich are still valid areappropriately monitored.

Medium/ Low The UHB will review WAO recommendations thatremain extant pre January 2014 and whereappropriate add them to the internal audit tracker,providing an update on actions taken.


Apr-16 Completed Update as at Sept 2016 - Recommendations are includedwithin the audit tracker which is presented at each AuditCommittee.

R12 2015 Jan-16 As part of programme andproject managementarrangements develop;a. robust benefit realisationapproaches andmethodologies which areused throughout the life of aproject.b. clearly identifiedarrangements to support thetransition of projects tooperational business asusual.c. reporting arrangementsthat require assessments orevaluations of benefitsachieved during the life ofprojects.

Medium/ Low The Health Board is already establishing improvedbenefits realisation planning in change projects.Reporting and monitoring of benefits achievementand associated decision making on projects doesneed further improvement, and this continues to bean important focus for the Board, which it iscommitted to improving during 2016/17.As part of project management, formal projectclosure arramgements will support the transition ofprojects into operational business.See response at (a) above.


2016/17 Completed Update as at January 2017 - we recognise that there is aneed for an increased focus in this area of the Board's workand this is being monitored via the Executove ProgrammeBoard work.

Update as at Sept 2016 - Arrangements are in place,supported by the Executive Programme Board and theProject Management Office (PMO), which takes into accountthese recommendations.

ICT Capacity & Resource Review (January 2017)








Committee/Group





15

R1 Jan-16 The Health Board needs toimprove the corporatecommitment to clinical ICT,by ensuring that:a. the profile of ICT is raisedat the ExecutiveManagement Team;b. there is a greater level ofclinical engagement with theICT programme, forexample, through theestablishment of clinicalchampions;c. a clear ICT benefitsmanagement programme isset out.

Medium/ Low There has been a discussion within the ExecutiveTeam that clarifies the direction of travel for ICTand Director portfolios going forward, which iscurrently being progressed.A Project Steering Group has been established tooversee the development of an ICT Strategy forCwm Taf UHB. A Strategy is being produced forconsideration by the Executive Board and HealthBoard.There is now an ICT clinical lead in place ensuringthe health board is represented at Nationalmeetings.There will be a requirement for more clinicalchampions and the establishment of a clinical ICTgroup within the health board will raise the profileof ICT and strengthen operational arrangementsthat will develop relationships with clinical areas.Benefits realisation will be included within the ICTstrategy.


June 2016/September2016

Dec-16 Completed March 17 update The ICT strategy and SOP have beencompleted by the external cnsultants it is currently out toreview with a deadline of the 6th April for comments. Thesewill be incorporated into the documents before going toExecutive Board for sign off August 2017 ICT Strategy andSOP has been approved by the HB and sent to WelshGovernment.

Update Received from Karen Winder Sept 16 - The ICTStrategy is under review following comments received fromExecutive Leads and feedback from the working group.Revised deadline of December 2016.Jan 17 Update - The ICT Strategy and SOP are beingreviewed and further developed by external consultants withan anticipated completion date of mid March 2017. This willthen be required to go to Executive Board for approval

R2 Jan-16 Given the separatearrangements between thedesign, support andmaintenance of informationsystems (IT), and themanagement of theinformation contained withinthe systems, the HealthBoard needs to ensure thatthese arrangements are nothindering the ability for allICT resources to provide apositive impact.

Medium/ Low The proposed way forward for ICT and InformationManagement, will bring a closer alignment to bothfunctions within the revised management structure.

Director ofWorkforce &OD

Oct-16 Feb-17 Completed March 2018 Update - "A key element of the revised proposalsis to establish an integrated management structure for PCH,Information and ICT under one Assistant Director.Implementation of the revised arrangements is planned tocommence 1 October 2016." I am unaware of any plan toachieve this objective. Otherwise, the action is complete withthe establishment of the new governance structures andappointment of the ADI for ICT.

Update Sept 2016 - An organisational change process ifdrawing to conclusion following extensive consultation. Akey element of the revised proposals is to establish anintegrated management structure for PCH, Information andICT under one Assistant Director. Implementation of therevised arrangements is planned to commence 1 October2016.Update February 2017 – Following the consultation processwe are now moving to implementation stage which willinclude the reinstate of the Assistant Director of ICT role andtransfer of the function to the Director of Finance. The role iscurrently out to advert on NHS Jobs with a closing date of28 February. March 2017 update Interviews for ADI postescheduled April August 2017 ADI interviews sheduled forOctober 2017. Update 1/11/2017 ADI interviews beingheld on 17th November 2017. Improved engagementarrangements in place and maturing with strengtheningclinical leadership. Update 20/12/2017 - ICT Steering Groupestablished Nov 2017; Clinical Leads in place Nov 2017;Digital Health Strategy agreed. delivery phase articulated inIMTP refresh; AD ICT appointed from 3/1/2018; ADInformation formally on ICT steering group.

R3 Jan-16 The Health Board needs tounderstand and address thenegative perceptions fromstaff in relation to inability tofully use the clinicalinformation systems thatcurrently exist within theHealth Board to ensure thatthe systems potential ismaximised.

Medium/ Low The development of the ICT Strategy provides anopportunity for strengthened communication andengagement.

By adopting a programme management approachkey stakeholders have been identified and anengagement plan developed.The recent appointment of a Clinical Lead for ICTwithin the Health Board will also strengthen links tokey clinical stakeholders.


Jun-16 Dec-16 Completed March 2018 Update - With the appointment of a Chief ClinicalInformation Officer, Chief Nurse Information Officer and thenew governance arrangements I believe this action iscompleted.

Update Sept 16 - The ICT Strategy is under review followingcomments received from Executive Leads and feedback fromthe working group. Revised deadline of December 2016.Jan 2017 Update - The ICT Strategy and SOP are beingreviewed and further developed by external consultants witha complishmnet date of Mid march. This will then berequired to go to Exec Board for approval March 17 updateThe ICT strategy and SOP have been completed by theexternal cnsultants it is currently out to review with adeadline of the 6th April for comments. These will beincorporated into the documents before going to exec boardfor sign offAll groups of staff have been involved in the review to raisethe awareness of ICT and listen to all points and incorporateviews and ideas. August 2017 ICT strategy signed off seeR1. Clinical IM&T lead and ICT have a working clinical group.Digital Steering group needs to be developed as arecomendation from the Strategy.Update 1/11/2017 First meeting of the Digital HealthStrategy group scheduled for 15/11/2017. First meeting ofthe Clinical ICT has occured and this group will be a subgroup of the Digital health group. Update 20/12/2017 - ICTSteering Grpup is developing its engagement plan for theDigital Health Strategy. For review 1/1/18

R4 Jan-16 To minimise the extent towhich there is lost time dueto system failures, theHealth Board needs toensure that adequaterecords are in place torecord unplanned downtime.

Medium/ Low Since this audit the stability of key clinical systemsused by the clinicians has improved. Service Pointhas been promoted and is used to documentsystem down time.

A service desk manager who is responsible formonitoring system, has been appointed.


N/A Completed

Consultant Contract WAO Report (March 2017)








Committee/Group





16

CC WAO01

Oct-16 NHS bodies should ensurethat all consultants have ajob plan that is reviewedannually to ensure that itreflects the business needsof the NHS organisation andthe continuous professionaldevelopment of theconsultant (Auditor GeneralWales National Report, Rec1a).

Medium/ Low Appoint Asst. Medical Director for ClinicalOperational Performance & Productivity.Convene Clinical Efficiency and Effectiveness group,chaired by the Asst. Medical Director for ClinicalOperational Performance & Productivity.- An e-Job Planning Manager was appointedFebruary 2016 to implement the system, andsupport the Directorate Management teams withcompliance.Allocate e-job planning Software® toolkit procured.Roll out Allocate e-job planning Software® acrossentire UHB.Upload corporate objectives to e-job plan as perIMTP.Upload directorate objectives to e-job plan as perIMTP.Develop a business intelligence platform(Cliksense) to aid visibility of quality, performanceand financial measurement.Agree process to capture PDPs from last appraisaland upload into e-job planning prior to job planreview.Develop training programme for DirectorateManagement teams and UHB business partners(planning, finance and HR colleagues) todemonstrate how they can support the job planningprocess. Training also needs to include section onagreeing and setting measurable outcomes.Develop slides on ‘The Job Planning Process - aguide to good practice’’. Share with colleagues atMedical Leadership Forum/Local NegotiatingCommittee/Hospital Medical Staff Committee.Upload to Sharepoint once agreed.Training sessions to also form part of an inductionpackage for all newly appointed DirectorateManagers, Clinical Directors and Medical and DentalPractitioners.

MedicalDirector

Dec-16 Completed Fortnightly meetings held with e-job planning team tomonitor job plan progress by Directorate.Directorate Job Plan summaries are available on Sharepoint -work continues with performance dept to feed these intoCliksense

CC WAO02

Oct-16 The Health Board has a jobplanning process in placewith most consultantshaving a current job planthat they indicated had beenreviewed within at least theprevious 18 months.However, the Health Boardneeds to ensure that allconsultants receive anannual job plan review.(Cwm Taf UHB Local Report,2011, Rec 1)

Medium/ Low e-Job Planning Manager and e-system in place tosupport the Directorate Management teams withcompliance.Agree process whereby the e-Job Plan Managermeets with individual Directorates to develop aschedule of job plan reviews for the forthcomingyear. Monthly reports to be developed to trackprogress. Monitoring and escalation process to beagreed with the Asst. Medical Director for ClinicalOperational Performance & Productivity.Monthly compliance metrics compiled and issued bythe Workforce and OD department for discussion inkey business meetings.A report on the rollout of e-job planning to betaken to Finance, Performance and WorkforceCommittee (F,P&W) in January 2017.Identify consultants who may have not had asigned job plan for more than 5 years and prioritisetheir next job plan review.Liaise LNC colleagues to agree a process for jobplan sign off.

MedicalDirector

Sep-16 Completed

CC WAO03

Oct-16 NHS bodies should ensurethat job planning issupported by up-to-datelocal guidance material andregular training for all staffwho participate in theprocess. (Auditor GeneralWales National Report, Rec1c)

Medium/ Low Planning Guidance for Consultant M&D Staff (April2014) plus ‘A UK Guide to Job Planning forSpecialty and SAS doctors (Nov 2012) has beenadopted by CTUHB as guidance to support the jobplanning process.Local guidance to be developed to support nationalguidance.[R1] Develop training programme for DirectorateManagement teams and UHB business partners(planning, finance and HR colleagues) todemonstrate how they can support the job planningprocess. Training also needs to include section onagreeing and setting measurable outcomes.[R1] Develop slides on ‘The Job Planning Process -a guide to good practice’’. Share with colleagues atMedical Leadership Forum/Local NegotiatingCommittee/Hospital Medical Staff Committee.Upload to Sharepoint once agreed.Training sessions to also form part of an inductionpackage for all newly appointed DirectorateManagers, Clinical Directors and Medical and DentalPractitioners.The Medical Director/Asst Medical Director willprovide a quarterly update on job planning atMedical Leadership forum and Executive Board toensure engagement of key staff.

MedicalDirector

Dec-16 Completed Developed in partnership with LNC Colleagues - for sign offSept 2017








Committee/Group





17

CC WAO04

Oct-16 The Health Board shouldprovide consultants withclear written guidance topromote a sharedunderstanding of the HealthBoard’s approach to jobplanning, including itsapproach to developingsmart outcomes. (Cwm TafUHB Local Report, 2011, Rec2)

Medium/ Low R3] All Wales Effective Job Planning Guidance forConsultant M&D Staff (April 2014) plus ‘A UK Guideto Job Planning for Specialty and SAS doctors (Nov2012) has been adopted by CTUHB as guidance tosupport the job planning process.

[R3] Local guidance to be developed to supportnational guidance.Medical & Dental Practitioner Website is underdevelopment in the UHB to accommodate links to e-systems, guidance documentation (as describedabove), policies, forms, performance information.Website development will also link in withRevalidation, Medical Personnel and MedicalEducation departments.[R1 & R3] Develop training programme forDirectorate Management teams and UHB businesspartners (planning, finance and HR colleagues) todemonstrate how they can support the job planningprocess. Training also needs to include section onagreeing and setting measurable outcomes.[R1 & R3] Develop slides on ‘The Job PlanningProcess - a guide to good practice’’. Share withcolleagues at Medical Leadership Forum/LocalNegotiating Committee/Hospital Medical StaffCommittee. Upload to Sharepoint once agreed.Training sessions to also form part of an inductionpackage for all newly appointed DirectorateManagers, Clinical Directors and Medical and DentalPractitioners.

MedicalDirector

Dec-16 Completed Developed in partnership with LNC Colleagues - for sign offSept 2017

CC WAO05

Oct-16 NHS bodies should ensurethat there is involvement inconsultant job planning fromgeneral managers to ensurethat wider organisationalobjectives, serviceimprovements, and financialissues are considered whenagreeing consultants’ jobplans, and to help managersunderstand what resourcesand support consultantsneed to deliver their job plancommitments. (AuditorGeneral Wales NationalReport, Rec 1d)

Medium/ Low The UHB will ensure that all job plan reviews areattended by both the Directorate Manager and theClinical manager. This will be reinforced in localguidance and at Medical Leadership Forum.It may also be considered that the Chief OperatingOfficer/Director of Primary, Community and MentalHealth, Asst. Director of Operations or UHBBusiness Partners attend job plans where teamsare going through significant service change orwhere there are particular service challenges.Job plan reviews for Clinical Director colleagues willbe undertaken by the Asst Medical Director and theAsst. Director of Operations.Review organisational objectives through ClinicalEfficiency and Effectiveness group and update e-jobplan as appropriate.

Ensure ‘Resources’ tab in e-job planning capturesany issues relating to staff, equipment, clinicalspace etc. to inform business cases, risk registersetc,

MedicalDirector

Sep-16 Completed Reviewed annually upon finalisation and submission of IMTP

CC WAO06

Oct-16 The Health Board needs tostrengthen existingarrangements by ensuringthat in all directorates, boththe Clinical Director andGeneral Manager attend thejob plan review meeting.(Cwm Taf UHB Local Report,2011, Rec 3)

Medium/ Low R5] The UHB will ensure that all job plans areattended by both the Directorate Manager and theClinical manager. This will be reinforced in localguidance and at Medical Leadership Forum.It may also be considered that the Chief OperatingOfficer/ Director of Primary, Community and MentalHealth, Asst. Director of Operations or UHBBusiness Partners attend job plans where teamsare going through significant service change orwhere there are particular service challenges.Job plan reviews for Clinical Director colleagues willbe undertaken by the Asst Medical Director and theAsst. Director of Operations.

MedicalDirector

Sep-16 Completed








Committee/Group





18

CC WAO07

Oct-16 NHS bodies should ensurethat they work jointly withuniversities in agreeing jobplans for consultants thathave academic contractssuch that the expectationsand requirements of bothorganisations are properlyand fairly considered; similararrangements should be inplace for consultantsworking for two or moreNHS organisations. (AuditorGeneral Wales NationalReport, Rec 1f)

Medium/ Low The UHB will maintain a list of individuals that haveacademic contracts, visiting consultants orconsultants who work for two or more NHSorganisations.

It will be the responsibility of the lead employer toundertake the job plan review and ensure thatrepresentation and or information is obtained fromthe university/NHS organisation to provide a robustoutline of the consultants workload andresponsibilities.Once agreed and signed off in e-job plan, the datacan be exported and shared with the ‘other’organisations.This expectation will be included during trainingand updates at Medical Leadership Forum.

MedicalDirector

Sep-16 Completed The medical staffing department hold a list of academic /visiting consultants for regular review and updates.

CC WAO08

Oct-16 NHS bodies develop aninformation ‘framework’ tosupport job planning, on aspecialty-by-specialty basis.Clinicians and managers willneed to work together toidentify the components thatneed to be included in sucha framework for eachspeciality, but it would beexpected to include:• information on activity;• cost;• performance against localand national targets;• quality and safety issues;• workforce measures; and• plans and initiatives forservice modernisation andreconfiguration. (AuditorGeneral Wales NationalReport, Rec 3)

Medium/ Low (Links to R1,3,4,12)Develop business intelligence platform to aidvisibility of quality, performance and financialmeasurement.

Work with performance and informatics team toadd information on• Concerns• Clinical Incidents• Legal Claims

Include signpost to the Performance summarydashboards in local job planning guidance.Recommend consultants access information prior toreview to support the job planning process.

MedicalDirector

Sep-16 Completed A number of QlikSense Applications exist to explore DatixInformation, specifically Complaints and Incidents.A daily database feed from the Datix system is used topopulate our QlikSense Applications with up to dateinformation.

CC WAO09

Oct-16 Where a specialty does nothave access to good qualityperformance information,the Health Board shouldstrengthen existingarrangements or developnew outcome indicatorswithin these specialties.(Cwm Taf UHB Local Report,2011, Rec 3)

Medium/ Low (Links to R8)Directorate Management teams are fully engagedin the development of the Demand and Capacityplans and this information is held locally withinspecialties as well as centrally within theorganisation.

In areas where the performance information withinthe business intelligence platform is still indevelopment i.e. Mental Health, Pathology, specificoutcome indicators will need to be developed inthese areas with input from the Clinical Directorsand Royal Colleges.Finance, Performance and Workforce Committee(F,P&W) will receive detailed reports on jobplanning (at least annually) as part of theworkforce metrics quarterly deep dives.

MedicalDirector

N/A Completed








Committee/Group





19

CC WAO10

Oct-16 NHS bodies should ensurethat they have clear androbust processes in place todiscuss and agree objectivesand outcomes forconsultants as part of thejob planning process. It willbe important to ensure thatclinicians and managersinvolved in setting theseobjectives and outcomesreceive the appropriatetraining and support toundertake effective jobplanning with consultants.(Auditor General WalesNational Report, Rec 4)

Medium/ Low (Links to R1)The IMTP sets out the organisation objectives andthese are pre-loaded into e-Job plan.These are then supplemented by departmentalobjectives, followed by personal objectives whichare mutually agreed.

[R1, R3 & R4] Develop training programme forDirectorate Management teams and UHB businesspartners (planning, finance and HR colleagues) todemonstrate how they can support the job planningprocess. Training also needs to include section onagreeing and setting measurable outcomes.[R1, R3 & R4] Develop slides on ‘The Job PlanningProcess - a guide to good practice’’. Share withcolleagues at Medical Leadership Forum/LocalNegotiating Committee/Hospital Medical StaffCommittee. Upload to Sharepoint once agreed.Training sessions to also form part of an inductionpackage for all newly appointed DirectorateManagers, Clinical Directors and Medical and DentalPractitioners.

MedicalDirector

Dec-16 Completed

CC WAO11

Oct-16 NHS bodies should ensurethat they have monitoringprocesses in place to checkthat all consultants have anup-to-date job plan, andthat job planning is beingundertaken in accordancewith guidance that has beenissued; monitoringprocesses should include anupdate report to the Board,at least annually, thatdemonstrates the extent towhich consultant jobplanning is embedded acrossthe organisation as a routinemanagement practice.(Auditor General WalesNational Report, Rec 1g)

Medium/ Low The UHB use information from e-Job plan and ESRBI to monitor compliance.The e-Job plan system issues auto-notifications 8weeks before the job plan review due date toensure Directorates consistently plan subsequentreviews.

Compliance reports are submitted monthly to theExecutive Board within the Integrated Performancereport.

A year-end report will be provided to ExecutiveBoard on job planning activity covering aspects ofcompliance, training, guidance, signed of job plansand outcome setting. The Asst. Medical Directorfor Clinical Operational Performance & Productivitywill oversee the report, supporting the MedicalDirector.

Non-compliant directorates will be asked to attendF,P&W Committee annually to demonstratecompliance with the JP process, and that job planoutcomes have been met.

MedicalDirector

Mar-17 Completed There are no cases of non-compliance to report currently.

CC WAO12

Oct-16 NHS bodies should ensurethat where changes to NHSservices are occurringfollowing public consultation,consultant job plans shouldbe updated and agreed toreflect new service models.This should happen as anintegral part of the processto redesign services, ratherthan a retrospective activitythat occurs after the newservices are in place.(Auditor General WalesNational Report, Rec 1b)

Medium/ Low Clinicians in CTUHB are actively involved in leadingthe work on service modernisation as part of theHealth Alliance and Collaborative programmes.As the work develops, the consultant body withinthe speciality is involved in developing proposalsfor the new service e.g. our paediatricians for thePaediatrics Future Services Model. Due to therequirement to reflect and agree service changeswithin a job plan, the JP process is very much apart of the programmes of work. A number of jobplans are already reflective of new ways of workingfollowing the development of new service modelsi.e. Consultant of the Week in Surgery, extendedhours due to new Acute Medical Model and newways of working for consultants supporting thefuture paediatric service model.

MedicalDirector

N/A Completed

CC WAO13

Oct-16 NHS bodies shoulddemonstrate more explicitlyhow consultant job planningis being used to support thedelivery of serviceimprovement andmodernisation, and theachievement oforganisational priorities andperformance targets.(Auditor General WalesNational Report, Rec 8)

Medium/ Low (Links to R8, 12, 13)Where service changes are occurring, these areoutlined in the IMTP. IMTP objectives feed into jobplanning via the Board and Departmentalobjectives.

The UHB can clearly demonstrate the number ofconsultant sessions allocated to support thedelivery of service improvement and theachievement of organisational priorities andperformance targets. The UHB maintains adatabase that clearly identifies individuals who holdkey roles in this work.

MedicalDirector

N/A Completed








Committee/Group





20

CCWAO14

Oct-16 NHS bodies should ensuretheir job planning processincludes a clear andinformed discussion on theSPA needs of individualconsultants, recognising thatthese will not be the same atdifferent stages in aconsultant’s career. The jobplanning discussion shouldspecify the SPA activities tobe included in the job plan,and identify the outputs andoutcomes that should beachieved, and the locationwhere these activities will becarried out. (Auditor GeneralWales National Report, Rec5)

Medium/ Low There is good evidence within the UHB thatdiscussions on the SPA needs of individualconsultants does occur during the job planmeeting, and this is captured within the e-job plansystem.

Measurable outcomes for all SPA will be recordedwithin the e-job planning system. An example ofgood measurable outcomes to be drafted andincluded in Local Job Planning Guidance.

A Clinical Efficiency and Effectiveness group willmeet monthly, chaired by the Asst. Medical Directorfor Clinical Operational Performance & Productivityto quality assure job plans for consistency mainly inregards to measurable outcomes and value of SPA.

MedicalDirector

Nov-16 Completed

CC WAO15

Oct-16 The Health Board needs toset out a clearer messageabout what constitutes SPAactivity, and that all SPAshave clearly definedoutcomes included in the jobplan review. (Cwm Taf UHBLocal Report, 2011, Rec 6)

Medium/ Low (Links to R14)SPA guidance will be developed in discussion withLNC colleagues that will suggest locally agreedtariffs to ensure parity of core SPA across the UHB,and will also include expected outcomes for coreSPA. Additional roles i.e. Educational Supervisoretc will also form part of this guidance.There are currently areas of good practice withinthe UHB and these will be engaged in developingthe SPA guidance to share good practice.

MedicalDirector

Sep-16 Completed Developed in partnership with LNC colleagues andincorporated into CTUHB job planning guidance. For sign-offSeptember 2017

CC WAO16

Oct-16 NHS bodies should look toadopt a team-basedapproach to job planningwhere it can be shown thatthis would be beneficial.Consultants would need tobe persuaded to participaterather than coerced, basedon a clear explanation of thebenefits associated with ateam-based approach, andshould still retain the rightto agree an individual jobplan with their employingorganisation. (AuditorGeneral Wales NationalReport, Rec 6)

Medium/ Low (Links to R12,13)Team job plan reviews are used to review therequirements for service change where required.Recent examples include Cardiology, A&E,Radiology and Anaesthetics.

Locally developed guidance & training will include asection on team job planning.

MedicalDirector

Sep-16 Completed

Radiology Report WAO Report (November 2017)RR WAO01

May-17 Develop an action plandetailing how waiting timetargets will be achieved inthe short term, and how theradiology service will sustaina reduction in waiting timesgoing forwards. (Setting outhow the use of locums, andoutsourcing of examinationsand other actions will helpthe Health Board achievetargets).

High Waiting Times Targets achieved for 2016/17, withno over 8 weeks waiting @ 31 March 2017.

Action Plan developed to sustain improved waitingtimes position which includes;• Additional capacity to be continued• CT & MRI commissioned for 7 day working• Continued use of Locum staff (13) (long and shortterm locums) whilst continuing to recruitsubstantive staff, across both DGH sites to supportCT, USS and General Radiology work.


Mar-17 Completed August 2017 Update - Planning ongoing against demandassessment. Locums in place and now recruited forultrasound. Outsourcing commissioned for MRI and CT fromApril to August. Demand and capacity reassessed and actionsrecomended.

RR WAO02

May-17 Develop an action plandetailing how reportingbacklogs will be managedsustainably.(Setting out how extendedpractice radiographers,outsourcing of reporting andother actions will achievereporting targets).

High Plan in place to develop UHB Action plan, whichincludes;• Reporting radiographer (lead post) currentlybeing recruited to - this post will coordinate andoversee development of radiographer reportingcapacity including identification of areas ofdevelopment, sourcing appropriate training andplanning capacity;• Expansion of radiographer reporting capacity inthe area of GP plain film underway, including betteruse of current Advance Practice Radiographers;• In the process of appointing to General ReportingRadiographer post, which will provide additionalcapacity to support further developments intoGP/Chest and Abdomen reporting


Jun-17 Completed August 2017 Update - Plans developed with options forsolutions included. Reporting options assessed. Reporitngradiographer recruited - will be central to planningradiographer reporitng expansion.

RR WAO03

May-17 Develop and implementregular auditing of reportingturnaround times andlost/late reports.

High Working with Information department to developan effective audit tool using Qliksense to;• Report turnaround times; and• Lost / Late reports


Aug-17 Completed August 2017 update - Reporitng turnaround informationbeing progressed with information depertment.








Committee/Group





21

RR WAO04

May-17 Review the appraisal andPDP rates of non-clinicalradiology staff. Ensure thatall radiology staff havereceived an appraisal andPDP within the previous 12months in line with theHealth Board’s target rate.

High There is a general improvement in PDP rates and acommitment to achieve agreed targets which areroutinely monitored at monthly Clinical BusinessMeetings (CBMs).

A forward plan of PDP dates is in place.


Dec-17 Completed August 2017 update - PDP rates rising - currently 65%

RR WAO05

May-17 Routinely review the numberof radiology staff compliantwith statutory andmandatory training, and seta target rate for complianceto be achieved in one andtwo years time.

High For Mandatory training, the target is 100% for level1 (Core Skills Training Framework) over a 2 yearperiod.Mandatory training compliance continues toimprove and there is routine monitoring ofperformance at the monthly CBM.


Aug-17 Completed August 2017 update - Mandatory training reviewed at CBM -rates rising.

RR WAO06

May-17 Develop a short termstrategy to address staffshortages of radiographers.

High The Directorate has a refreshed 3 year IntegratedMedium Term Plan (IMTP) for this coming, whichincludes workforce planning.

The Directorate is engaged fully with the workforcemodernisation lead in order to take forward itsrecruitment strategy, which includes maintainingLocum staff (short and long term locums), whilst itcontinues to recruit graduates and its recruitmentstrategy is being taken forward.

Radiology specific modernisation workshop heldand the related actions that help in identifying newopportunities are being taken forward.

Similar to our Nurse and Medical recruitmentcampaigns, the UHB has commissioned an externalmarketing organisation to work with us on ourrecruitment and information campaign forRadiology.


Aug-17 Completed August 2017 update - Strategy in place with extended use ofnon-professional band 2 and 3 roles to support radiographerfunctions. Radiologist recruitment strategy included inreporitng plans. Locum radiographers recruited intopermannent posts where possible. Recruitment campaignaddressed with HR and Jamajar consulatiants plus articles tojournals.

RR WAO07

May-17 Develop a plan/strategy withreferring specialties toidentify both major andminor changes that willimpact on radiology demand(such as recruitment of newconsultants, changes topatient pathways, etc).

Medium/ Low The Directorate has developed a Demand &Capacity Plan, referenced within the DirectorateIMTP, which includes;

• Ensuring demand assumptions are based on acombination of national benchmarking and localmonitoring of demand rises;• Engaging with referring directorates - e.g. cardiacservices, primary care clusters;• Working with information department on demandand capacity modelling.• Ensuring Radiology directly involved with pathwaychanges such as Early Cancer pathway / vaguesymptom clinics.• Radiology to work with planning to formalisechange planning approach in regard to Radiology


Jun-17 Completed August 2017 update - IMTP cooperation with referringdirectorates addresses integrated planning. Radiologyinvolved in planning for new services / transfers of servicesand development of cluster hubs.

RR WAO08

May-17 Develop a radiographerworkforce plan alongside theradiology strategy, whichidentifies the baselinecapacity needed tosustainably meet radiologydemand in a timely and safeway.

Medium/ Low The Directorate’s IMTP which links to its workforceplan and related recruitment Strategy (linking withthe Radiology Strategy), includes;• Demand & Capacity Plans;o Additional Sonographerso Additional Radiographers

Further related work is being progressed toconsider the most appropriate skill mix (includingoptions for grade and skills) of staff required forscanning.The workforce plan (within the Directorate IMTP,will be revised in line with business partner inputand support. August 2017 update - Workforce planunder development. Majotr actions completed -strategy / plan for diagnostic hub recruitment andskill mix modelling.


Aug-17 Completed October 2017 update - Workforce plan implemented andbeing recruited to - Hub now operational - training underway.IMTP workforce plan to be compiled for 2018-19

RR WAO09

May-17 By mid-2017 identifypotential staffingrequirements for theDiagnostic Hub, and developa recruitment strategy.

High Project for diagnostic hub staffing underwayincluding assessment of requirements of staffingand skill mix to enable hub commissioning.

Strategies for recruitment and retention ofgraduates are also included within the plan.


Aug-17 Completed October 2017 update - As above - recruitment implementedfor hub and skill mix contributing with recruitment of band 2and 3 to workforce. Radiographer open days planned forNovember 2017 for radiographer recruitment 2018.

August 2017 update - As above - recruitemnt underway forhub and skill mix contributing.








Committee/Group





22

RR WAO10

May-17 Further develop the range ofperformance measures tosupport business reports byreviewing existing measuresand identifying gaps.Measures should includeequipment usage, thenumber of unreportedimages, average reportturnaround times, longestreport turnaround times andwaiting times.Workforce measures such asplanned versus actualstaffing levels, vacancies,sickness rates, and appraisaland PDP rates along withcompliance against trainingshould also be reported.

High A suite of performance measures is already in placeand been developed during the year as aconsequence of strengthened business intelligencesystems, including QlikSense. This includes;• Waiting times are reported to CBM currently –including numbers over 8 weeks – currently 0.• PDP and Appraisal rates, along with Core SkillsTraining Framework compliance are reported toCBM, currently – these are not included in theDirectorate report submitted to WAO and form aseparate element of the CBM agenda.• Vacancies and recruitment positions / plans arereported to CBM currently.• Sickness rates are reported to CBM currently.• Compliance against training is reported to CBMcurrently.

Further measures including reporting indicators willbe agreed and developed and factored intodirectorate reporting, aligned with establishautomatic reports via Qliksense software.


Oct-17 Completed October 2017 update - Unreported examinations beingreported routinely in directorate twice weekly - to DM and ADand senior radiographers / radiologists. Work underway withinformation colleagues to further address reportingturnaround times via Qliksense. Measures reported to CBM asitemised left. Home reporting partially implemented to assistwith reporting capacity.

August 2017 update - Unreported examinations beingreproted routinely in directoroate. Work underway withinformation colleagues to address reporting turnaroundtimes. Measures reported to CBM as itemised left.

Structured Assessment 2016 (January 2018)R1 2016 Feb-17 Board Assurance Framework

R1 In order to better identifyboard assurancerequirements, the HealthBoard should:• articulate its strategicobjectives more clearly byusing sub-objectives oraims; and• include in-year IMTPpriorities

High The Board has, as part of its refreshed IMTP for2017-20, developed improved strategic and relatedobjectives, whilst also considering its ‘draft’ well-being objectives and goals linked to therequirements of new legislation. Further work isalso being currently undertaken on this in the newIMTP 2018-2021 in order to improve links betweenstrategic objective setting and objectives withinpersonal development plans (PDPs) across theorganisation.

The UHB has developed in year IMTP priorities andthese are in part aligned to the Board AssuranceFramework. This remains very much work inprogress as part of the Health Board’s evolution ofits IMTP and BAF.


Mar-17 Completed

R2 2016 Feb-17 Audit CommitteeR2 The Audit Committeeshould:• ensure that it hasappropriate arrangements inplace to regularly review andmonitor assurances withinthe Board AssuranceFramework; and• develop a forward workprogramme to assist thecommittee plan andtimetable meetings.

High A Forward Work Programme has been developedfor the Committee. Arrangements are in place (aspart of the Committee’s forward plan) to receive atleast twice annually the BAF.

Director ofFinance

Jul 2017/Feb 2017

Completed

R3 2016 Feb-17 Committee effectivenessR3 The Health Board shouldensure:• all reports to Board andcommittees adopt therevised report template; and• the report template is usedto clearly articulate thepurpose of the report andthe action/ decision requiredwhen plans and polices arereported to Board andcommittees.

High This is in place for Board and Board Committees.Ongoing monitoring by corporate secretariat is alsoin place.

This is in place and will periodically be consideredas part of the annual self assessment of BoardCommittees.


Ongoing Completed

R4 2016 Feb-17 Committee effectivenessR4 Complete the design andimplementation of thesupporting structures for thenewly created Quality,Safety and Risk Committee.

High Following consideration and further discussion atthe September 2017 meeting of the Quality, Safety& Risk Committee, it has been decided not toproceed with the establishment of an assurancesub group and instead to work to develop andimprove directorate exception reporting. Theremaining sub Committee working arrangementsare generally agreed and in place.

Director ofFinance

Jun-17 Completed








Committee/Group





23

R5 2016 Feb-17 External ReportsR5 The Health Board shouldensure that reports from theDelivery Unit are subject tothe organisation’sgovernance and assurancearrangements.

High The Board will ensure related reports from the DUare more formally considered where appropriate inthe Board’s governance & assurance arrangements.However, it should be noted that matters reportedinto and considered by the Board’s Finance,Performance & Workforce Committee is also a keyelement of the Board’s Governance and Assurancearrangements.

Director ofFinance

Ongoing (as& whenreceived)

Completed

R6 2016 Feb-17 Combined follow-up ofInformation Managementand Technology auditsR6 Address the pace atwhich outstandinginformation managementand technology auditrecommendations areaddressed.

High The Board has now agreed a lead Executive for theDirector ICT portfolio and more recently hasproposed a revised governance approach which isbased on re-establishing the ICT Steering Groupwith stronger and more appropriate representation.It’s also important to note that some ICTrecommendations will take longer than intendedand as a consequence discussions have taken placeto ensure more accurate assessment of timescalesis included when responding to audits relating toICT.


Apr-17 Completed

R7 2016 Feb-17 Financial controlR7 Strengthen currentarrangements for financialcontrol and stewardship by:• agreeing consistent rolesand responsibilities of staffleading the cross cuttingthemes for savings; and• agreeing a consistentapproach and terms ofreference for ClinicalBusiness Meetings asrecommended by InternalAudit.

High The Health Board has recently reviewed andreplaced its Executive Programme Board andinstead established the Efficiency, Productivity andValue Board. The related Terms of Reference havebeen agreed and approved by the Executive Boardand shared with Finance, performance & WorkforceCommittees.The Clinical and Corporate Business Meeting Termsof Reference have been drafted for consideration bythe lead Executives and more generally theExecutive Team. This will be considered,developed and adopted over this coming quarter.


2017/18 Completed

R8 2016 Feb-17 Financial performanceR8 Strengthenarrangements for themonitoring and reporting ofsavings plans againsttargets by ensuring there isclear accountability,understanding and reportingof why savings are notdelivered.

High Revised arrangements have been introduced tostrengthen the reporting and monitoring of savingsplans across all Directorates of the Health Board,including a strengthing of Directorate and crosscutting theme financial reporting into the Efficiency,Productivity and Value Board . This Board also hasa role (by exception) to consider the non deliveryof Directorate Savings Plans and related RecoveryPlans, escalated as appropriate.


2017/18 Completed

Review of GP Out of Hours (October 2017)GP OOH01

Sep-17 Include a variety of methodsto engage and encouragestaff to participate in servicedesign discussions anddecisions, especially mobilestaff and those workingshifts.

High Regular Executive and Senior management teamled evening meetings with GPs currently workingwithin the OOH service already take place and thiswill continue. Feedback from GPs is very positiveregarding the value of these meeting. Regularmeetings take place with representatives of all staffgroups.To work with the communications team and thePrimary Care Communications Officer to agree anaction plan around staff engagement as there aremany things which can be offered.

Director ofPrimary,Community &Mental HealthServices

Oct-17 Completed

GP OOH02

Sep-17 Give regular updates andopportunities for furtherparticipation to staff as plansdevelop.

High Regular meetings take place with all staff groups Director ofPrimary,Community &Mental HealthServices

Oct-17 Completed

GP OOH03

Sep-17 The Health Board shouldreview current managementteam capacity. Options couldinclude introducing an extratier of management orformalising on-callarrangements amongstexisting staff.

High An on-call rota out of hours has now been put inplace since May 2017.A new Band 6 role was introduced during December2015 and this is providing additional resilience tothe Band 7 and Band 8b roles.


Oct-17 Completed








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24

GP OOH04

Sep-17 The Health Board should asa matter of urgency, addressthe ongoing data integrityissues that are currentlypreventing meaningfulcomparisons with otherhealth boards, to ensure theHealth Board has anaccurate position of its GPout-of-hours performance.

High A significant amount of work has already takenplace in order to try and resolve these issues.External consultancy has been engaged viaAdastra. Whilst this has achieved someimprovement problems still exist.A data analyst has also been recruited specificallyfor Primary Care and has also been working toextract the data out of the Adastra System and linkit with Qliksense in order to provide more reliabledata. The plan is to link the data extrapolated fromQliksense into the UHBs business intelligentsystem.Data to be reported as part of the Primary CareDashboard.


Mar-18 Completed June 2018 update - An upgrade to Adastra is takinng placeacross Wales during the Summer of 2018 which should resultin improvments to data reporting. This upgrade is coupledwith ongoing work relating to performance data as part ofthe 111 workstream.

March 2018 update - still ongoing.

GP OOH05

Sep-17 Update the Health Boardwebsite to include thefollowing:‒ Choose Well informationon the landing page;‒ a dedicated page for GPout-of-hours service with adescription of the service;‒ examples of types ofconditions/circumstanceswhen choosing the out-of-hours service would beappropriate;‒ GP out-of-hours serviceopening times; and locationsof the primary care centres.

High The report indicates that at the time of the auditthere was limited patient information on the UHBswebsite as it was being updated at the time. Thereis now an updated page on the website. Thisaction point also links with Response 1 and theneed for a ‘Comms plan’. Not all patients accessthe UHBs website and therefore other avenues forcascading information to be explored.A new leaflet has been drafted and distributed to allGP practices advising of when and where theservice is available and how to access it,Information can be displayed within GP surgerieson the television screens and other partner agencyinformation sources.


Mar-18 Completed

GP OOH06

Sep-17 Work with GP practices toensure messages on theirwebsites and answerphonesare consistent. Perhapsdevelop standard text for allpractices to adopt.

High The primary care team will work with the PracticeManagers Group in the development of guidancefor practices.


Dec-17 Jul-18 In Progress March 2018 Update - An audit of telephone messages iscurrently being undertaken and this will inform thestandardised messaging. This will need to go throughformal process with LMC. June 2018 update: The results forthe audit of the OOH messaging is on the agenda for theJuly 2018 LMC / UHB liaison meeting

GP OOH07

Sep-17 Encourage GP practiceswithout a website to developone, and include informationabout the GP out-of-hoursservice on their websites.

Medium/ Low The use/development of practice websites is nowinclude as one of the items for monitoring at theannual practice development visit undertaken bythe primary care team.Promotion of My Health on Line is a priority for2017-18.


N/A Completed

GP OOH08

Sep-17 Include telephone triagetraining as part of GPinductions.

Medium/ Low Telephone triage has now been included into theinduction programme.A copy of an RCGP approved publication ontelephone triage is issued to all triaging GPs.


N/A Completed

GP OOH09

Sep-17 Offer formal telephonetriage training to existingGPs working for the service.

Medium/ Low Formal telephone triage training was offered to allGPs during 2017. A training programme wasdelivered during June 2017, which was wellattended. A copy of an RCGP approved publicationon telephone triage is also issued to all triagingGPs.


N/A Completed

Discharge Planning (March 2018)DP 01 Jan-18 Discharge Planning Policy:

Our assessment of theHealth Board’s policyindicates that it could bestrengthened when it is nextreviewed. The Health Boardshould include:

a patient dischargeleaflet;

the discharge checklist;

the escalationprocedures;

arrangements for patientsdischarged from A&Edepartments ormedical/clinical assessmentunits;

electronic links to theHospital Discharge Protocolfor Patients in HousingNeed, the Choice ofAccommodation Protocol andthe Continuing NHS CareFramework; and

a flow chart or decisiontree to support decisions onwhether discharges aresimple or complex and thepathway to follow.

Medium/ Low The Discharge Planning Policy is due for review inSeptember 2019 however we will complete an earlyreview and revise the document in order to reflectupon the audit recommendations


Dec-18 Completed Dec 2018 update - The Discharge Planning Policy is currentlyin final draft format. As part of the patnership agenda thepolicy has been reviewed with LA colleagues and includes theChoice Process. A pilot is underway in YCR which supportsfamilies through the Chioce process and montors the timeframe. The Discharge Planning Policy & Choice protocol wasratified by Primary Care & Localities Quality & Safety meetingon January 8th 2019 and forwarded to the UHB Quality,Safety & Risk committee meeting for ratification on the 7thMarch.








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25

DP 02 Jan-18 Discharge Pathway: Thesteps in the dischargepathway are not clearly setout in the DischargePlanning Policy. The HealthBoard should set out eachdischarge pathway as a clearsequence of steps;

ensure that all pathwaysare available in one place –such as the Discharge Policy,with links provided in otherrelated policies/guidance;and

ensure that staff areaware how to accessdischarge pathways.

Medium/ Low The Discharge Planning Policy is due for review inSeptember 2019 however we will review and revisethe document early in order to reflect upon theaudit recommendations


Dec-18 Completed March 2019 Update - The WAO recommendations have beenincluded in the revised Discharge Planning policy & ChoiceProtocol and agreed with partners.

December 2018 update - The Discharge Planning Policy iscurrently in final draft format. As part of the patnershipagenda the policy has been reviewed with LA colleagues andincludes the Choice Process.

DP 03 Jan-18 Patient leaflet: Adapt thecommunity hospital patientleaflet so it is relevant forpatients staying in acutehospitals, setting out

information about thedischarge process,

how the patient andfamily will be kept informedof the discharge process;

arrangements that thepatient may need to make(such as arrange transport);

information about follow-up care; and

the complaints process.

Medium/ Low A patient information leaflet is already in place andused on the community hospital sites. The UHB willnow consider the development of an acute hospitalinformation leaflet.


Sep-18 In Progress

DP 04 Jan-18 Monitoring performance orcompliance: Although, theHealth Board’s DischargePlanning Policy and draftDischarge Protocol include arange of both qualitative andquantitative measures tomonitor compliance, theseperformance measures haveyet to be reportedsystematically to the Boardor its committees. TheHealth Board shouldregularly report on thesemeasures.

High The draft discharge protocol needs to be finalisedand signed off by the UHB and its local authoritypartners as a priority action early in 2018.


Completed March 2019 update - The revised policy includes evaluationoutcomes that can be reported to Board.

December 2018 update - Agreement has been reachedbetween both LA patners and the UHB regarding themeasures to be used going forward. These have beenincluded in the draft policy.

Structured Assessment 2017 (June 2018)SA 201701

Apr-18 The Health Board’s QualityImpact Assessment Tool,which must be completed forschemes over £100,000,currently asks directoratesto consider the impact oftheir savings schemes on:patient safety, clinicaleffectiveness, patientexperience and staffexperience. The HealthBoard should extend thetemplate to also cover theimpact of large savingsschemes on otherdirectorates and services,other health bodies andexternal partners andorganisations.

High The Health Board will ensure the current templatesin use, are extended to cover the recommendationmade. These will be developed to inform the 2019-2022 IMTP process.

Director ofFinance

Nov-18 In Progress December 2018 update - The use of the QIA tool will bereinforced for the 2019/20 planning and delivery cycle.

SA 201702

Apr-18 We found that the HealthBoard’s IMTP peer reviewprocess does not fullyidentify potential cross-directorate workingopportunities andduplication. The HealthBoard should review andstrengthen the process tobetter facilitate joint savingsschemes and identify similaror duplicate schemes.

High The Health Board will ensure its current processesare reviewed and strengthened in the arearecommended and its findings will inform the 2019-2022 IMTP process.

Director ofFinance

Nov-18 In Progress December 2018 update - This is currently ongoing as part ofthe 2019-2022 planning cycle, due to complete in the lastquarter of this year.








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26

SA 201703

Apr-18 We found that there can becomplexities to cross-directorate working,especially if directorates donot directly benefit fromsavings schemes. The HealthBoard should develop a setof principles for directorates,which encourages Health-Board-wide working.

High The Health Board will develop a set of principles fordirectorates to adopt which encourages Health-Board-wide working. These will inform the 2019-2022 IMTP process.

Director ofFinance

Nov-18 In Progress December 2018 update - Further work has been undertakenfor 2019 – 2022 to better define how cross-cutting themesavings opportunities impact on Directorates and where thebenefits are realised.

SA 201704

Apr-18 We found the Health Boardhas limited projectmanagement and dataanalytics capacity and skillsto support savings planningand delivery, especially forHealth-Board-wide schemes.The Health Board shouldreview and considerenhancing current projectmanagement and dataanalytics capacity and skills.

High The Health Board has recognised its deficits inrelation to project management capacity/capabilityand data analytical support. Additional capacity isbeing resourced on data analytics and the UHB’sGraduate Management Training Scheme isequipping all Trainees with Project ManagementSkills. June 2018 update - The Health Board hasrecognised its deficits in relation to projectmanagement capacity/capability and data analyticalsupport. Additional capacity has been resourced ondata analytics in the last 6 months and the UHB’sGraduate Management Training Scheme hasequipped all Trainees with Project ManagementSkills. In addition, during the first part of this year,additional capacity and capabilities were alsobrought into the PMO, on a fixed term basis, by theFinance Department This assisted with projectmanagement and subject matter expertise to anumber of the cross-cutting themes includingplanned care. One of these post has been extendedfor a further 3 months. Resource in both these areswill be kept under review and given the recentadditional capacity provided to assist, it isrecommended that this action is now closed but itwill be kept under review by the Executive.


Jun-18 Completed

SA 201705

Apr-18 The Health Board shouldfurther refine the IMTPreporting process to includedetailed information onmilestones to enable IMs tounderstand the currentperformance in line withexpected trajectory.

High The Board has made progress in this area over thelast year and continues to explore all avenues tofurther refine and improve reporting arrangements.Indeed, Auditors have also been asked to helpidentify and direct the UHB to best practice.


2018/19 Completed December 2018 update - Further improvements have beenmade to the reporting process to take on board Health Boardmembers comments on strengthening the report.

SA 201706

Apr-18 The Health Board shouldensure there is a detailedresourced action plan toenable delivery of the DigitalHealth Strategy.

High The Digital Health Strategy whilst ambitious, willrequire a series of related business cases that theHealth Board will need to consider and prioritisewithin its overall capital programme.


2018/19 Dec-18 In Progress December 2018 update - The Digital Health Strategy is builton a set of annual priorities expressed over a five yearstrategic staircase. Over the course of this year the strategyhas prioritised the development of three business cases,with two that link into national procurements: digitisation ofrecords is a foundational commitment to digitise 1.25mmedical records, the final business case has been signed offand will shortly be shared with the Welsh Government tofinalise funding routes; Emergency Department systemprocurement is due at Board in December 2018; and theEprescribing and underpinning pharmacy system will cometo Board before the end of the financial year 2018/19.

SA 201707

Apr-18 The Health Board needs toimprove the quality of itspapers presented to thequality, safety and riskcommittee:• making the papers moresuccinct and focussed (somepapers viewed were overlylong and complex); and• consider the agendamanagement for examplebringing more complexissues to the beginning ofcommittee, and movingapproval of polices to thelatter end of the agenda

High We will continue to work with Director colleagues toensure the quality of Committee Papers andstructure and focus of its agenda continue toevolve, mature and ultimately improve.Completed

Director ofNursing

2018/19 Completed

Primary Care Services (February 2019)








Committee/Group





27

PC 01 Jan-19 The Health Boardcommissioned the PrimaryCare Foundation to carry outdemand and capacityassessments in GP practicesbut the take-up frompractices has been variable.To maximise value from thecommissioned work, theHealth Board shouldcentrally analyse and collatethe messages from thedemand and capacityassessments and share thelearning across all practices.

High Currently this is being undertaken and theoutcomes will be shared at Cluster meetings, thePrimary Care Strategic Planning Group andreported through to the Primary Care Committee.Numerous practices have implemented changesand this will be captured and shared as a keyelement of this work.


Dec-18 Mar-20 In Progress March 2019 update - Delay as a National set of AccessStandards have been released and the work needs to beconsidered in conjunction with this. Bridgend boundarytransfer has also an impact and there the work is deferred toend of March 2020.

PC 02 Jan-19 Calculate a baseline positionfor its current investmentand resource use in primaryand community care.

High This work has commenced and will be a crucialelement in determining the baseline position for theprimary and community element of the Cwm TafPartnership Transformation Plan.


Mar-19 Mar-20 In Progress March 2019 update - Bridgend practices now have to beconsidered as part of the workplan. Deferred for March2020.

PC 03 Jan-19 Review and report, at leastannually, its investment inprimary and communitycare, to assess progresssince the baseline positionand to monitor the extent towhich it is succeeding inshifting resources towardsprimary and communitycare.

High The Cwm Taf Partnership Transformation Plan willrequire that a thorough assessment is made inregard to the impact of investment in primary,community and social care on the whole health andcare system. This will require reporting to WG andalso through the Regional Partnership Board as wellas internal efficiency and productivityarrangements.


Mar-20 In Progress

PC 04 Jan-19 The Health Board’sworkforce planning isinhibited by having limiteddata about the number andskills of staff working inprimary care, particularlycommunity dentistry,optometry and pharmacy.The Health Board shoulddevelop and implement anaction plan for ensuring ithas regular, comprehensive,standardised information onthe number and skills ofstaff, from all professionsworking in all primary caresettings.

Medium/ Low The Health Board through the Oral Health and EyeCare planning arrangements will commence during2019/20 more detailed work on the workforceissues in Dentistry and Optometry practices. Inparticular skill mix approaches and professionalshortages. The CDS service will have beenrepatriated and a full workforce analysis andmodernisation approach will be undertakenThe Cwm Taf Transformation plan places greatstore on MDT working of which the role ofpharmacy and pharmacists is crucial. Workforceplanning in this area is key and will be workedthrough the Transformation Plan


Mar-20 In Progress

PC 05 Jan-19 Work with the clusters toagree a specific frameworkfor evaluating new ways ofworking, to provide evidenceof beneficial outcomes andinform decisions on whetherto expand these models.

High The Public Health Local Team have supported theclusters in evaluating a small number of schemesalready but not all. In addition to this they haveproduced a template evaluation framework forclusters. The use of this template needs to beencouraged for all schemes. Detailed evaluation isan essential part of the new transformation plans todemonstrate the impact of the extended MDT team.


Mar-20 In Progress

PC 06 Jan-19 Centrally collate evaluationsof new ways of working andshare the learning bypublicising the keymessages across all clusters.

High A Primary Care Newsletter is in existence and isproduced quarterly. This newsletter is intended forprofessionals and is shared across the clusters,between contractors and community.


Ongoing Completed

PC 07 Jan-19 Work with the public topromote successful newways of working, particularlynew alternative first pointsof contact in primary carethat have the potential toreduce demand for GPappointments.

High Work has already commenced with this as part of‘know your own team campaign’. A plan for2018/19 has been produced. Engagement withclusters is essential.Opportunities to engage will be taken via media,press, existing forums and groups and events.


Ongoing In Progress

PC 08 Jan-19 Evaluate the effectiveness ofthe Health Board’s newprimary carecommunications officer roleand share the learning withall health boards in Wales.

High This process is already in place andevaluation/success measures are already detailedin the delivery agreement which is reported to theWelsh Government on six-monthly basis. Sharingof learning across Wales takes place via all Walesforum of Heads of Communication.


Ongoing Completed








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28

PC 09 Jan-19 Review the relative maturityof clusters, to develop andimplement a plan tostrengthen its support forclusters where necessary.

High Significant support is already given to clustershowever they will need to evolve both as part ofthe strategic direction set by the WelshGovernment in A Healthier Wales and to fulfil theexpectations and requirements of the transformedmodel. In addition, a new governance frameworkhas been issued on a national basis and will beused locally as part of the delivery of thetransformation plan to support clusters in theirmaturity.


Mar-20 In Progress

PC 10 Jan-19 Review the membership ofclusters and attendance atcluster meetings to assesswhether there is a need toincrease representation fromlocal authorities, thirdsector, lay representativesand other stakeholdergroups.

High This has been undertaken and steps are in place tostrengthen the primary care cluster structure.


Mar-19 Completed

PC 11 Jan-19 Develop an action plan forstrengthening clusterleadership.

High Various options will be offered to cluster leads inorder to fit their skills and experience and toprovide flexibility. This will be explored at clusterleads meetings. An array of options are alreadyavailable through their PCCI Hub


Mar-20 In progress

Structured Assessment 2018SA18 01 Apr-19 We recommend that within

12 months, the Health Boardfully implements theoutstandingrecommendations from ourprevious StructuredAssessment (as detailed inAppendix 1).

Medium/ Low We fully accept this recommendation and willcomplete the outstanding work within 12 months

Chief Executive Mar-20 In progress

SA18 02 Apr-19 The Health Board shouldupdate the Scheme ofDelegation to reflect therequirements of the NurseStaffing Levels (Wales) Actto designate a seniorregistered nurse to calculatenurse staffing levels.

Medium/ Low The Scheme of Delegation will be amended toreflect the requirements of the Nurse Staffing(Wales) Act

Director ofNursing

Apr-19 Completed

SA18 03 Apr-19 To improve risk practice andprovide assurance to theBoard and Committees thatrisks to achieving strategicobjectives are effectivelymanaged, the Health Boardshould:‒ a) undertake anorganisational wide reviewof the directorate riskregisters to ensure they areup to date and reflect thecurrent risks facing services;and‒ b) ensure timely on-goingreview of all directorate riskregisters.

Medium/ Low Fully accept the recommendation. BoardDevelopment session on risk management to beheld before the Summer.

The Head of Operational Health Safety and Fire willreview all risk registers on Datix and work withDirectorate Managers and Assistant Directors toreview all risk registers and agree the process forongoing review at Clinical /Corporate BusinessMeetings


Oct-19 In Progress To be held before the July meeting of the Audit Committee.

To report to the October meeting of the Audit Committee








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29

SA18 04 Apr-19 To improve qualitygovernance arrangementsthe Health Board should:‒ a) ensure the QualitySteering Group meets withthe appropriate frequency;

‒ b) ensure that the qualityreport is more explicit athighlighting quality concernsand also articulates how theHealth Board is learninglessons;

‒ c) consult with the publicand service users whendeveloping the new QualityStrategy‒ d) improve the quality andconsistency of Quality,Safety and Rick Committeepapers to ensure clarity andbrevity, to enable areas ofconcern to be identifiedeasily, to highlight actiontaken to address areas ofconcern and to demonstratelearning;‒ e) audit the quality, safetyand risk processes withindirectorates to gainassurance they operateeffectively;

‒ f) review the relevance oforganisation policies that theQuality, Safety and RiskCommittee is asked toapprove and reallocateresponsibility to othercommittees; and

‒ g) provide bespokeinduction for IndependentMembers newly appointed tothe Quality, Safety and RiskCommittee to ensureeffective scrutiny andunderstanding of qualityissues.

Medium/ Low Fully agree with the recommendation to improvequality governancea) Quality and Safety Framework developed andagreed; new sub groups to be developed.b) Quality Report to be changed and moreinformation provided through a dashboardapproach; ensure lessons are learned aredisseminated across the Health Boardc) Will consult with service users and the public todevelop the strategyd) Improving the information for the QSR willinvolve the sub groups meeting to discuss theoperational detail and the Chair will report back tothe Committee on a range of issues which willinclude learning lessonse) Directorates will be required to hold Governancemeetings and a template to report exceptions to asub group of the QSR for discussion will bedevelopedf) New sub groups will be developed to over seeand endorse policies; a report outlining the processincluding engagement and consultation will beclarified; the Committee will then provide final signoff.- Corporate- Clinical- Workforceg) All IMs will have a bespoke induction programme- wider discussion on scrutiny and quality issueswill take place at a Board development session.

Director ofNursing

Various In Progress

SA18 05 Apr-19 The Audit Committee shouldensure the tracker logrecords good information toenable IndependentMembers to review and takeassurance that therecommendations arecomplete when removedfrom the tracker;

Medium/ Low R5 The reasons for removal of recommendationsfrom the Audit Tracker will be clarified for Ims


Jul-19 In Progress

SA18 06 Apr-19 The Audit committee trackershould be expanded toinclude therecommendations of otherexternal agencies e.g.Healthcare InspectorateWales and the Delivery Unit.

Medium/ Low R6 A new tracker (based on the Audit Tracker) willbe developed for recommendations of externalagencies and regulators. The audit tracker isalready of a considerable size and concerns wereraised that adding recommendations could be lost.This new Tracker will report to the Quality Safetyand Risk Committee.

Director ofNursing

Jun-19 In progress

SA18 07 Apr-19 The Health Board shouldtake steps to strengthen theoversight arrangements inrelation to ICT andInformation Governance by:‒ a) ensuring that minutesfrom the Digital HealthStrategy Steering group andInformation Governancegroup are scrutinised at theQuality, Safety and RiskCommittee; and‒ b) clarifying andarticulating links betweeninformation governance andICT to strengthen theoversight and scrutiny of theTrust’s digital business

Medium/ Low R7 Following discussion, the Health Board hasdecided to have an ICT Committee which willsubsume the work of the Information GovernanceGroup. The Committee will report to Board on allmatters.a) This recommendation will not be required as theICT Committee will report to the Boardb) The new Committee will scrutinise informationgovernance / ICT and the work in relation to thedigital strategy


Sep-19 In progress

SA18 08 Apr-19 The Health Board shoulddevelop a cyber securityaction plan to implementrecommendations from theNHS Wales External SecurityAssessment and any othercyber security reviews asappropriate. It should alsobe used to ensure that cybersecurity arrangements are inplace to meet the HealthBoard’s needs.

Medium/ Low R8 The ICT Committee will be responsible foroverseeing the development of the cyber securityaction plan and implement the recommendations ofthe external security assessment.


Dec-19 In progress








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30

SA18 09 Apr-19 We recommend that theHealth Board put in place anaction plan to ensure thatthe matches it receives infuture NFI exercises arereviewed. We expect theHealth Board to.‒ a) Commence review ofthe data-matches as soon aspossible following therelease of the next NFImatches in January 2019;‒ b) In addition to reviewingall the high priority matchesrecommended for review,carry out a review of asample of the remainingdata matches; and‒ c) Ensure that where data-matches have beenreviewed, the NFI webapplication is updated toclearly record how matcheswere reviewed and theoutcomes of those reviews.

Medium/ Low R9 The HB will develop an action plan to ensurethat the NFI exercises are reviewed.

a) Work commenced on the data matches in April2019b) All high priority matches will be reviewed as wellas a sample of the remaining data matchesc) The NFI web application will be updated torecord actions taken

Director ofFinance

Oct-19 In progress

Clinical Coding Follow Up ReviewCCFU 01 Oct-19 Raising the importance of

good quality medical recordsthroughout the HealthBoard;

High In 2014, we found that the quality of medicalrecords across the Health Board was not of a goodstandard, with key information required foraccurate clinical coding often missing orinappropriately filed.Our work has found that there continues to beissues with the quality of medical records within theHeath Board. In 2018, NWIS produced a report intoclinical coding documentation. This review wasundertaken as part of ongoing service improvementwork to improve the quality of clinical coding data.The primary aim of this review was to assess thequality of the clinical documentation held withincase notes. Overall administrative documentationwas of good quality, but there were issues withloose paperwork and records being filed out oforder. There were also issues with deceased notesand unplanned admissions. The quality ofinformation for coders in the notes was poor. Onlyhalf of the clinical entries contained a diagnosis andof these, a third would be unable to be used forcoding purposes. This report highlights that thereare issues that need to be addressed by the HealthBoard.

In our 2014 report, we noted the re-establishmentof the Health Records Committee. The aim of thiswas to give the necessary focus to the quality ofmedical records to enable coders to codeaccurately. However, this Committee wasdisbanded in August 2017 and we are unaware ofany new arrangements in place to monitor andensure the quality of medical records.


Notspecified bythe HealthBoard

In progress Update January 2020The completeness of the documentation is the responsibilityof multiple staff groups across the hospital sites. Both thecontent and quality of the record will be improved throughthe plans now being implemented to commence digitisationin November 2019. This process will reduce the risk ofdocuments being lost from within the record as they will bescanned and held digitally. E-forms will also be introducedto capture information electronically, live at the point ofcare. These forms will be structured and will require theclinical user to provide answers to mandatory questions anduse standard terminology through the use of drop-downmenus. This should aid completeness and accuracy, as wellas legibility of information captured. Digitisation of thecritical mass of active patients is expected to take 2 years tocomplete, but improvements will begin for individualpatients from the point of go-live. Rollout of e-formdevelopment is planned to commence in April 2020 and thiswill involve a development programme gradually convertingexisting paper forms to e-forms. Work will be done toidentify those which are highest priority for development,but this is likely to target the highest volume and leastcomplex forms in the first stages. These measures will assistin regards to the completeness of the record and the timelyavailability of information.Greater focus is needed on every aspect of medical recordsmanagement, which is clinically led and an organisationwide.

CCFU 02 Oct-19 Clarifying roles andresponsibilities for medicalrecords amongst clinicalsupport staff, such as wardclerks and medicalsecretaries, including filingand general recordmaintenance

Medium/ Low The review in 2014 highlighted that the medicalrecords team had responsibility for setting up therecord and ensuring that it is stored correctly.These arrangements have continued with medicalrecords retaining responsibility for the movementand storage of files but not the contents. We arenot aware of any specific work undertaken to clarifythe role and responsibilities for medical records forany other staff.



In progress Update January 2020Medical Records teams are responsible for filing referralletters and continuation sheets. Responsibility for themaintenance of the Health Record is shared across Medicalrecords Department, ward clerks, outpatient receptionistsand Medical Secretaries.Greater focus is needed on every aspect of medical recordsmanagement, which is clinically led and an organisationwide.








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31

CCFU 03 Oct-19 Developing a programme ofroutine audits of medicalrecords to provide assurancethat the quality of medicalrecords is improving;

Medium/ Low The quality of the patient record has a directimpact on the coders ability to undertake their role.As highlighted previously, work by NWIS into thequality of documentation highlighted concerns withloose paperwork, and the filing of deceased patientrecords.As part of the annual clinical audit andeffectiveness plan, there is currently a Health Boardwide audit of the quality of case notes. This audit islooking at documentation in case notes and isaligned to the health records committee, howeverthis committee has been disbanded so we areunsure where the results of this audit are reviewed.The current audit plan shows that this audit wasalso undertaken last year but there is no record ofthe report. The results of the current audit are duefor publication in March 2019.



In progress Update January 2020The content and the quality of the Health record is theresponsibility of all clinical users adding information to therecord and this is monitored and reported by the ClinicalAudit team. This is emphasised within staff inductionprogrammes where the importance of accurate HealthRecords and the impact on Clinical Coding is noted.The Management Board have approved additional resourceto recruit a Clinical Coding Auditor/Trainer and our statedintent within our IMTP is to take this action forward utilisingthis much needed resource.

CCFU 04 Oct-19 Reviewing the arrangementsfor filing result slips inmedical records, taking intoconsideration the electronicreporting function of clinicalsystems

Medium/ Low In 2014, we found that there were issues releasingmedical records to the coding teams because of abacklog in results slips being filed. Werecommended that this issue was resolved toensure that medical records were freed up in atimely manner. However, we are not aware of anywork being undertaken to address this issue, whichcontinues to be problem.



Completed Update January 2020Result slips are now actioned electronically and no longerprinted

CCFU 05 Oct-19 Putting steps in place toensure that medical recordsare released to clinicalcoding teams as soon aspossible after discharge.

Medium/ Low Our last review found that on average coders weregetting access to medical records within 6 weeks ofdischarge, but some could take longer than threemonths to reach the department.Currently the Health Board is undertaking mappingwork to understand where medical records aregoing. They recognise that coders need timelyaccess to the records to meet the completenesstarget. Coders are working to get notes directlyfrom the wards but sometimes they need to berequested from the central hub at Williamstown.There is a positive working relationship betweenmedical records and coders and recognition whycoders need timely access to the records. The hubis open 7 days a week and medical records allowcontract coders to work directly from the hub onweekends to address the backlogs.



Completed Update January 2020Clinical coding has a strong working relationship with MedicalRecords and support not only day to day working but alsocontract coders who work at the weekend. We currently haveno issues with these processes.

CCFU 06 Oct-19 Setting out a clear plan forsuccession planning of staffover the next five years,which will provide anopportunity for developing aclear career pathway andimplementation of theaccredited clinical coderqualification;

Medium/ Low Staffing levels have been problematic for thecoding teams. In our 2014 report we highlightedthat there was a shortfall in the staffingestablishment. In 2017, Internal Audit also raisedconcerns around the shortfall in staffing levels andthe ability of the team to efficiently process thevolume of hospital episodes and to meet the WelshGovernment target.The Health Board has recognised this issue and hasincluded a workforce plan in the strategy for thedevelopment for the clinical coding department.This strategy is set out clearly within the IntegratedMedium-Term Plan for the Performance andInformation Directorate.The Health Board has also introduced formal ‘AnnexU’3 clinical coder training posts which aresupported by a structured two-year internaltraining programme. These posts are trainee roles,and staff are appointed on an initial 24-monthcontract during which time the individual will besupported to work towards accreditation. Theincrease in trainee role however does not increaseproductivity significantly and can have adetrimental impact, as qualified coding staff needto support and check their work.Trainees also reported that they felt there was notenough support for them during their training toprepare them for exams. They also reported thatthere is no formal structure to the training ormilestones to work towards and keep track ofprogress. The Health Board needs to consider howit will support all levels of staff to develop andprogress their careers.


Apr-14 Completed Updated 2020Our training plan has evolved over the last two years and wenow have a single ACC qualified supervisor providingdedicated support to all trainees. This provides consistencyand continuity to their training programme. Once theeligibility criteria are met, this supervisor will study for boththe official training and auditor qualifications.In addition, in accordance with national guidelines, all teammembers attend refresher training and workshops as outlinedwithin the NWIS training programme. These dates are allrecorded on individuals ESR records.The succession planning arrangements are detailed in theIMTP. The plan involves having a dedicated supervisor oneach site, as well as a dedicated auditor post. The plannedstructure clearly shows the potential for progression throughthe Department, with internal applications for advertisedposts being encouraged and welcomed at all times.








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CCFU 07 Oct-19 Providing support formembers of the team toachieve the clinical codingauditor qualification, and theimplementation of a localprogramme of clinical codingaudits;

Medium/ Low In 2014, we found that there was no localprogramme of clinical coding audit and a lack of aqualified clinical coding auditor within the HealthBoard meant that this could not be put in place.Since then, the Health Board did support anindividual to attain the audit qualification, howeverthey gained promotion into a national role soonafter qualifying. The Health Board recognise thisgap in their team, have been unable to find acoding course for them to achieve the qualification.


Mar-15 In progress Updated January 2020Our plan is to support a member of the team to achieve theauditor qualification. The restriction on this is that you needto be ACC qualified for two years before becoming eligible tostudy for the qualification. The staff member who will studyfor this qualification does not fulfil the criteria at present.

CCFU 08 Oct-19 Reviewing the allocation ofworkload across the teamsto ensure that clinical codingdemand is evenlydistributed;

Medium/ Low The allocation of workload has remained consistentwith our review in 2014. The Health Board has ageneral approach across the clinical coding teamsat the two district general hospital sites. Coderstake the records in chronological order to coderegardless of the speciality to which the episoderelates. Trainees rotate through the specialties togive them experience. However issues withallocation of workload have remained the same.



Completed Updated January 2020All work is stored chronologically and each coder selectstheir own records to code. The aim is to complete eachmonth in accordance with Welsh Government targets and tomeet our internal productivity targets. Individuals are giventheir performance in a weekly report. This allows for anyissues or support needed to be highlighted by individuals ifthe target is missed. In addition this performance measureis included in the PDR process.

CCFU 09 Oct-19 Encouraging whole teammeetings which bringtogether all clinical codingstaff from across the sites;

Medium/ Low A whole team meeting for all sites was trialled.However, this meant that all staff were away fromcoding duties at the same time so it was stopped.Communication however has been identified as anissue. Staff are told they can raise any issues tomanagers, but the team feel that nothing is doneabout issues when they have raised them. Thecommunication between management and thecoding teams appears to be poor and morale is low.We understand that the Health Board haveundertaken considerable work to improvecommunication, and there is executive awarenessof the issues. Further work is needed to bringcoders together and develop better trust betweencoders and management.



Completed Updated 2020We continue to have site based staff meetings every 6-8weeks. The teams are however encouraged to raise issues orconcerns at any time. These meetings have strengthened thecommunication within the team and there are no barriers towider communication across all the sites.

CCFU 10 Oct-19 Using opportunitiespresented by team meetingsand individual appraisals toprovide regular feedback tostaff on issues raisedthrough validation and audit

Medium/ Low A PDR process is in place which gives a chance forfeedback to staff on issues raised through routinevalidation. Additionally, there is regular informationavailable on staff productivity through an electronicsystem which is used across the Health Board.However, there is currently no clinical codingqualified auditor within the team, so there is noregular casenote audits being undertaken.



Completed Update January 2020The department has had three NWIS Annual Audits covering20169/17, 2017/18 and 2018/19. In all three audit resultsthe % accuracy for coding assignment has been met and/orexceeded the required levels. We are waiting for the fullreport for 2018/19. The two previous reports identified goodprogress and provided assurance to the quality of clinicalcoding.

CCFU 11 Oct-19 Raising awareness of theclinical coding processadopted by the Health Boardthrough training sessions formedical staff, as well asattendance at appropriatemeetings such as auditsessions;

Medium/ Low In 2014, we highlighted there was limited clinicalengagement in clinical coding. Since then, theHealth Board has attempted to raise awareness ofclinical coding by attending sessions some sessionsclinical staff, for example recent engagement withENT consultants but the extent to which this hashappened has been limited and adhoc. Staffcapacity within the coding team has been identifiedas the main reason.



In progress Update January 2020The Clinical Coding Manager is currently working withGastroenterology, Haematology and Obstetrics, to improvethe Information that is used for coding.The Clinical Coding Manager has also attended the MTEDuser group meetings to try to improve the quality ofinformation on the Discharge Advice (DAL)At present due to the high volume of trainee Clinical Codersand the limited number of qualified Clinical Coders we haveto deliver targets, visiting clinical areas regularly is achallenge. We do however encourage such engagement,since it is beneficial to both parties and there areenthusiastic clinical staff who are keen to understand thedifferences between clinical terminology which they use dailyand clinical coding classifications, which they are lessfamiliar with and come across less frequently. We will lookto increase this interaction as we take forward our plans forimproving the service.

CCFU 12 Oct-19 Raising the awareness of thelocation of the clinical codingteams across the sites;

Medium/ Low In response to our 2014 recommendation, it wasidentified that a departmental open day would beheld to allow staff the opportunity to review codingsystems, books and results.However, there has been no evidence to suggestthis went ahead or any other initiatives to raiseawareness of the location of the teams.


Sep-14 Completed Update January 2020These took place in 2014/15 and were supported by theproduction of bilingual leaflets describing not only the role ofclinical coding and the clinician in the process but the uses ofcoded activity. These will need to be updated as there havebeen a number of changes in personnel and in light of theboundary change to incorporate information in relation to thePOW team.








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CCFU 13 Oct-19 Encouraging clinical codingstaff to engage clinicians inthe validation process and tovisit clinical areas.

Medium/ Low An identified model of good practice is to engageclinicians in the validation process. However, staffare reporting issues with accessing cliniciansbecause it is time consuming and they often do notget a reply. The coding team however haveestablished a single point of contact in ENT forcoding queries, but this appears to be the onlyarrangement that is in place. Where engagementoccurs elsewhere, this appears to be reactive toconcerns about the quality of coding. For example,cardiology approached the coding team when theywere receiving data which did not match what theywere expecting. This discussion has howeverprovided an opportunity to raise the importance ofgood quality case notes to support the codingprocess.



In progress Update January 2020We are optimistic with the role out of i Compare CHKS, thatthis will further raise awareness to Clinical Staff of theimportance of Clinical Coding. We also raise awareness ofClinical Coding through the Junior Doctors Inductionprogramme. At present, we are also engaging with ClinicalStaff via the National Audit Programmes for Heart FailureDementia and Stroke, where during this process clinicallycoded data is validated by Clinicians and Senior CodingOfficers.

CCFU 14 Oct-19 Providing short briefingmaterial which clearly setsout the implications of poorclinical coding (reflectingtimeliness, completeness

and accuracy) on keyperformance indicators;

Medium/ Low The Health Board has maintained its surveillance ofits coding performance, and both completeness andaccuracy feature as part of the Health Board’s keyperformance indicators which are reported toBoard. The detail and benchmarking information inthese have improved since our last review.The information highlights the backlog and theactions being taken. However, the report does notexplicitly highlight the impact the backlog has onthe quality of data.The results from our board member surveyidentified that 87% of those responding said theywould find it helpful to have more information onclinical coding and the extent to which it affects thequality of key performance information. Since ourprevious work, the Health Board has hadconsiderable churn of Independent Members whomay benefit from training on clinical coding



In progress Update January 2020Clinical Coding performance continues to be reported via thePerformance Dashboard Report, reflecting the codingposition for the past 12 Months. Timeliness Completenessand Accuracy taken from CHKS i Compare are also keyindicators that are reported each month within theorganisation benchmarked against the Welsh peer group..There is an accompanying narrative outlining the actionsand any issues affecting the production of clinical coding.

CCFU 15 Oct-19 Ensuring that papers thatare underpinned by clinicalcoding data, such as theperformance managementreport, planning documentsinclude a statement whichsets out the robustness ofthe data

Medium/ Low In our original review there were regularperformance reports to the Board in respect ofcoding. At the time these reports were highlightingsignificant backlogs in coding activity. The levels ofbacklog were not dissimilar to the current reportedposition in March 2019. At the time, the risks toother reported performance data because of clinicalcoding backlogs was identified as an extreme riskand featured in the Health Board’s corporate riskregister.Clinical coding does not currently feature on theHealth Board corporate risk register, nor is therereference in any papers that rely on clinical codingdata to the impact that the backlog, for example,can have on the quality of data.



Completed Update January 2020Any report produced from Clinical Coding or Clinical Codingdata, if necessary, will include a caveat highlighting therobustness of the data. In addition and supporting dataquality, we currently have a large number of internal DataQuality Indicators that highlight specific coding standards e.g.where signs and symptoms may be coded as a primarydiagnosis, where a review is required. These are presentedto the individual coder for investigation and correction wherenecessary. Also apart from the Annual Clinical Coding Auditundertaken by NWIS, they also produce regular Data Qualityindicators, presented through a dashboard, providing usefulfeedback on any areas requiring review and correction.

CC NEW01

Oct-19 Resolve the current interimarrangements by agreeingthe coding managementstructure following thedirectorate reconfiguration,ensuring there is sufficientmanagement andsupervisory capacity.

Medium/ Low The plan to support these changes are included inthe Departmental IMTP 2019/20-2021/22


Mar-20 In Progress

Structured Assessment 2019SA 201901

Feb-20 Committee StructuresThe Health Board needs toensure that the newsubcommittee structuresadequately support sufficientscrutiny of important areasof business and servicedelivery. We found that keyareas such as Strategy andPlanning, Workforce andMental Health would benefitfrom improved coverage.

High Committee structures were reviewed by the Chairin August 2019 and subsequently the ‘Primary andCommunity Services Committee’ became ‘Primary,Community, Population and PartnershipsCommittee’. Mental Health will feature as a keyelement in this committee in its re-purposed focusand the Terms of Reference will be reviewed toreflect this.Proposal to strengthen assurance to the Board isunder consideration with a view to implementationearly 2020. Proposal includes;• Succession Planning for Chair of Q&S Committee• Frequency of Committee meetings• Establishment of a new WOD Committee,resulting in greater focus for Planning and FinanceIntroduce Guidance on Deep Dives• Mechanism for Committee Reporting to Board• Board Development & Board Briefings• Meetings held in Public


February2020/March 2020

In Progress








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SA 201902

Feb-20 Committee ProcessesThe Health Board needs toensure that the deep diveprocess is usedappropriately, and sufficienttime is allocated to discussthe results of any deep diveprocess in the relevantcommittee.

High Introduce Guidance on Deep Dives for Committees– linked to proposal in R1.


Mar-20 In progress

SA 201903

Feb-20 Performance ManagementArrangementsWe found that performancemonitoring is sound andcomprehensive, but someimprovements can be madeto information received bythe Board and itscommittees. The HealthBoard should review theformat and legibility of theperformance dashboardcurrently reported to Boardand sub committees toenable a better overview ofwhere performance hasimproved or deteriorated toenable more effectivescrutiny and greatertransparency.

High Work has been underway for some months tofurther improve the performance dashboardreporting to the FPW Committee and Health Board,with a specific, short bullet point summary at thebeginning of the document to encapsulate anumber of key issues where performance hasimproved or deteriorated. This has been receivedfavourably by FPW Committee members.Further work has also been carried out on the FPWCommittee’s Forward Work Programme to agreespecific areas of interest where members would liketo focus their attention on specific areas ofperformance concern.However, it is acknowledged that furtherimprovement work is always required, which will bedeveloped in tandem with Board Members’feedback and the associated development of thequality dashboard in particular. It will also beupdated to reflect any changes made to the NHSDelivery Framework.

Director ofPlanning andPerformance

Phase 1 –December2019Phase 2 –September2020

In progress

SA 201904

Feb-20 Change managementWe found that the HealthBoard has a significantprogramme of work todevelop and implement theIntegrated HealthcareStrategy, and strategictransformation plans withindirectorates. The HealthBoard should evaluate thecapacity within theProgramme ManagementOffice to ensure it issufficient to effectivelysupport servicetransformation projects.

High As detailed in the CTM Organisational ImprovementPlan, the on-going development, and fullestablishment of ‘Improvement CTM’ will enhancechange management capacity alongside furtherrecruitment to project management to ensure morerounded programme management capacity in theorganisation.On-going recruitment of project managers andidentification of staff who already havebronze/silver/gold IQT training will strengthen thecapacity across the organisation and are creating amore coherent approach to align our BevanFellowships and Exemplars with organisationaltransformation objectives.

Director ofPublic Health

Full Est. byApril 2023/December2020

In Progress

SA 201905

Feb-20 IMTP ReportingWe found that the HealthBoard has revisited IMTPreporting this year and isreporting against the WelshGovernment accountabilityrequirements. However, oneof the accountabilityrequirements from WelshGovernment is that thereneeds to be increased clarityon actions, deliverables andmilestones for all aspects ofthe plan which is scrutinisedby the Board. Werecommend that the HealthBoard should:• review the content of thecurrent IMTP quarterlyreports to ensure theycontain sufficientinformation on the deliveryof the three-year plan andinclude the performanceagainst overall objectives,and the annual priorities;and• review the annualsummary of IMTP reportingto focus more on theoutcomes and impact of thework undertaken during theyear.

High Welsh Government have revised their IMTPreporting requirements in 2019/2020 and we havebeen following a new template, together withproviding supporting information. These appear tohave been well received by both the Health Boardand Welsh Government to date, with no specificchanges or updates requested.In drafting the IMTP 2020-2023 however, we arealso aiming to be more specific wherever possibleon adding further delivery information includingmilestone dates, anticipated performanceachievement and outcomes for various aspects ofwork which should allow us to further improve ourIMTP progress reporting both to the Health Boardand Welsh Government

Director ofPlanning andPerformance

Apr-20 In Progress








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SA 201906

Feb-20 The Health Board hasincluded sustainable savingsand efficiency in its plans,but these have under-achieved over the last twoyears. The Health Boardshould assess the reasonsfor under-achievement toensure realistic plans are setand achieved in 2020-21.

Medium/ Low N/A In progress

SA 201907

Feb-20 A range of benchmarking isused for planning, serviceimprovement and efficiencywork, but scope exists toextend the information usedin respect of costs. TheHealth Board shouldprogress its developmentand use of costing so that itbetter informs financialplanning and management.

Medium/ Low The Health Board has in recent years used costinginformation to benchmark performance and informservice planning through:• Use of the UK wide Patient Costing Benchmarkingtool, allowing comparison of unit cost and costdriver information with a range of Englishproviders.• Inclusion of cost information in the internalclinical variation tool.• Use of patient level costs to inform currencies forinter Health Board Funding Flows.• Development of a Commissioning activity Tool tounderstand internal variation from a populationhealth perspective.• Support of specific pathway redesign projects.It has been our experience that it has been hard todevelop service engagement around benchmarkingof fully absorbed unit costs – more so in the Welshenvironment where tariff-based payments andService Line Reporting are not operational.In pursuit of technical efficiency therefore theapproach has moved towards benchmarking thefactors that underpin variation in unit cost:• Cost Drivers – indicating how efficiently well weare using our capacity• Cost Base – identifying potential savings in thedelivery of that capacity – through workforce,procurement etc.The recent focus of the costing function has been toidentify opportunity from cost driver efficiencyparticularly in respect of patient flow, theatres andoutpatients – making use of CHKS and internalinformation sources.Moving forward the development and use of costinginformation will be developed in the context of theNational Efficiency Framework developed by theFinance Delivery Unit which focuses onTechnicalEfficiency• Population Health Efficiency• Whole Systems IntelligenceSpecific priorities for the costing function in thenext year will be:• To refine the cost driver benchmarkinginformation shared within the organisation toidentify opportunities for technical efficiency.• To support development of PIDs developed byKPMG in cost driver functions.• To build a ‘front end’ to the Costing system toincrease service awareness of fully absorbedservice costs.• To develop a better understanding of variation ofresource utilisation at cluster level in the context ofthe new needs-based allocation formula and keyoutcome measures.• To contribute to the national PLICs/National DataRepository development group with specific focuson:‒ Lung Cancer‒ Knee Pain‒ Stoke pathway‒ Alignment of patient cost information with theNational Data Repository.• To support local Value Based Projects and inparticular, to support the correlation of cost:‒ with PROMs information at a patient level as itbecomes available.‒ to support detailed pathway reviews led byClinical Reference Groups.

Director ofFinance

Mar-21 In Progress

Implementing the Wellbeing and Future Generations ActIWFG 01 Feb-20 Begin to explore the

potential for long-termfunding prior to completionof the pilot, so thatmomentum can be sustainedin the event of a successfuloutcome.

Medium/ Low The Health Board recognises this is a challenge.Funding has been agreed for 2020/21 from theEarly Years Pathfinder grant. This is a pilot, theoutcomes of which will need to be considered bythe PSB and WG to determine if there is valuetaking this work forward in the long-term acrossCTM and Wales. If the pilot is successful andaccepted as a more effective mechanism to targetsupport, the longer term future role out anddelivery will need to be discussed with WelshGovernment, in the context of Cwm Taf Morgannwgas well as any benefit to other regions of Wales.


Feb-20 In Progress

IWFG 02 Feb-20 Continue gathering evidenceon the causes ofvulnerability to inform themodel over time.

Medium/ Low This is a resource intensive commitment at a locallevel. It was intended to be a one off piece of workto inform the pilot. There is no capacity locally totake this forward. It will be shared with the EarlyYears Pathfinder programme and the F1000Dsnetwork. If it is considered beneficial to update itnationally, periodically, it would be agreed at afuture date. Public Health Wales could potentiallytake a lead on this as a once for Wales approach.


TBA In Progress








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IWFG 03 Feb-20 The Health Board and itspartners have different waysof working and need to worktogether to recognise thosedifferences in order toovercome any barriers theymay present.

Medium/ Low This is well recognised. One of the key areas is totry to get consistency of approach across 3 LAareas when requesting/commissioning of servicesfrom the UHB. There have been discussions tohighlight the need for consistency in the provisionof Maternity and Health visiting services so thatstaff are not requested to provide different servicesin different areas. Also acknowledgement ofdifferent IT software systems in different LA’s. Thishas led us to look at whether SAIL could be used toovercome this issue.The joint working in pilots like this presents theopportunities to recognise differences, learntogether and build trust across the system. Forexample, different organisations have differentcapacities and experience in undertaking analysis.For this reason, the multi-agency group agreed thatRhondda Cynon Taf would pilot this project as theyhad a bigger team with experience in profilingchildren and young people at risk of not being ineducation, employment or training (NEET). It wasagreed that all local authorities would be on theSteering Group so that the learning and barrierscould be explored jointly.


Mar-21 In progress

IWFG 04 Feb-20 Agree the terms of referencefor the Steering Group toensure good governance,with a clearly defined remit,responsibilities andaccountabilities.

Medium/ Low Terms of reference have now been agreed alongwith an action plan detailing responsibilities forfacilitate good governance. This will be updated iffunding is secured to complete this pilot.


Nov-19 Completed

IWFG 05 Feb-20 Plan a follow-on system-wide engagement event toinform people aboutprogress to date and to pavethe way for the next phaseof development, ensuringthat it includes people withappropriate technical andgovernance expertise.

Medium/ Low This is would add value and help communicationand consideration will be given to this later in thepilot. Two qualitative involvement projects areplanned to inform the next phase of this pilot:• Pregnant women, parents of young children andwider public views on data sharing for this purpose.• Political leaders and senior staff of partnerorganisations for views on sharing data for thispurpose and any concerns or barriers toimplementation.This will be picked up through the VulnerabilityProfiling work stream.


Jun-20 In Progress

IWFG 06 Feb-20 Included in the report butnot in the managementresponseParagraph 10: No evidenceof progress on CorporateArrangements

Medium/ Low This is a recognised need within the Health Boardand consideration will be given to this. The findingsof this audit will be reported back through the AuditCommittee of the Health Board to consider thefindings, opportunities to strengthen corporateassurance and oversight and respond accordingly.The Committee meets quarterly and the report willgo to the next available Committee upon receipt bythe Health Board. Any actions identified will bemonitored through the Audit Committee. Inrecognition of the partnership context of this workstream, it will also be reported back to the Cwm Tafand Bridgend Public Services Boards and theChildren and Young People’s Sub Group of the CwmTaf Morgannwg Regional Partnership Board. Anyactions identified will be reported upon throughthese mechanisms also.Work is underway to explore how the corporatearrangements for WbFG within CTMUHB can bestrengthened. This will include clarity around theassurance, Governance and oversight as well asincorporating the legislation into planningprocesses.


Jun-20 In Progress








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red - implementation date passed management action not ... and risk...update as at jan 2017. pilot...

Documents