YORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL. Deputy/ Associate Director. Executive Director TRUST WIDE

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1 YORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL CQC findings TRUST WIDE Ensure that at all times there are qualified experienced staff (including Staff communication engagement 1. Refresh workforce strategy plan monitor delivery a) Refresh strategy plan b) Implement milestones/ quarterly review c) Review refresh leadership management training to align to Trust strategy 2. Implement changes to streamline recruitment processes a) implement new recruitment policy b) implement the new track system. c) implement fast track for agency staff d) implement new temp to perm process. e) Complete options appraisal for in-house staff bank 3. Increase engagement with system partners to support workforce development via LWABs other regional local working groups. 1. Continue to promote the expectation of visible leadership in all management roles. 2. Implement refreshed communication strategy including increased use of social media, YAS TV improved website design. 3. Establish new behavioural framework following Trustwide consultation exercise. 4. Ensure at least 90% of staff receive an annual appraisal in accordance with new target 5. Continue to develop partnership approach through Trust service line JSG meetings. 6 Support dissemination of good practice highlighted in inspection across the Trust, with focus on learning improvement, staff recognition support. 7. Complete Datix refresh to include easier usage, automatic feedback communications. 8. Develop launch a consistent approach to service quality improvement, rooted in active engagement of patients staff Chief, Planning Deputy Deputy Communiccations Training Deputy Deputy fo Deputy fo 1. Ongoing 2. Ongoing - quarterly 3. June 17/ March 18 Sep-17 March 2018 March 2018 April 2018 Dec-18 Risk Assurance, Deputy Quality Nursing 1a) Sept 1a) Refresh oftrust workforce strategy plan in progress 1b) Milestones to be agreed 1b) 1review 1c) Sept 2a)June 2b) Sept 2c) April 2d) April 2e) Dec 2a) of trac system in progress 2b) of fast track for agency staff in progress 2c) Temp to perm process under review 2d) Options appraisal for staff bank now commenced 3a) Initial discussions mapping of relevant meetings under way. Plan in place to refresh consult on new vision values. Speaking to minimum 10% staff for feedback on proposed vision/values. Following this there will be an organisation wide survey a full engagement programme. Also a full launch at Management Conference. Corporate target now set to 90% for PDR's. Monthly breach report discussed at Locality Corporate Management meetings. JSG meetings strengthened, with additional moperational meetings now in place for A&E, NHS 111 Feedback via newsletters presentations on good practice highlighted. Successful Safety Huddle pilots in EOC being extended to NHS 111. Launched 1 April. Communications completed. Roadshows scheduled to support launch. ACTION COMPLETE Bright Ideas scheme re-launched. Critical Friends Network established to support patient engagement in service improvement. YAS Forum also supporting. Discussions with Healthwatch planned for Q1. Scoping work pilot developments under way to inform options review by TEG. Publication of new workforce strategy plan Staff in post/skillmix against plan Delivery against staff education training plan Sickness absence rates Improved recruitment timelines Reduced agency usage Staff survey results PDR rates constant breeches Positive qualitative feedback on partnership Confirmed examples of good practice shared incidents reported staff survey Training delivered Feedback on staff manager engagement Pilot initiatives in selected departments

2 Ensuring that at all times there are qualified experienced staff (including Child seats/harnesses not always accessible on vehicles - Ensure secure seating for children is available on vehicles Review arrangements for start of shift vehicle check staff should have sufficient time to complete checks Ongoing processes to ensure that equipment medical supplies are checked fit for purpose Consistency of audit procedures for controlled drugs Consistency in clinical waste sharps disposal in stations vehicles Consistent availability of specialised equipment for bariatric patients Consistency of implementation of station security health safety processes Staff ability to highlight concerns to contribute to improvements in practice 1a) Implement refreshed training recruitment plan. Full establishment by July 1b) Evaluate current Clinical Supervision pilots implement learning across A&E service 1. Ensure all A&E transporting vehicles have a child harness available on board 1. Review reinforce arrangements to ensure that they are implemented consistently across the Trust 1. Implement a regular testing programme for medical equipment. 2. Continue to follow consumable supply process 1. Review audit procedures for reviewing the recording of all medicines present recommendations to CGG. 1. Continue to promote best practice through education associated communications. 2. Reinforce consistent implementation through Clinical Supervision, IPC Nurse site visits I for I process, with targeted interventions where necessary. 1. Roll out new bariatric equipment as part of the introduction of new A&E vehicles. 2. Ensure full awareness of the new SOP for access to support equipment for bariatric patients. 1. Actively promote good practice in station security via staff communications line management processes. 2. Feed back on practice issues arising from fire risk assessments to local managers staff 3. Implement programme of Estate works to address issues highlighted through fire risk assessments 4. Implement health safety training for all managers 1. Continue to actively promote Bright Ideas scheme 2. Support involve staff in team-based quality improvement activity 3. Ensure local staff meetings are in place to support discussion of ideas for improvement 4. Continue to promote Freedom to Speak Up Guardian role, Finance Medical, A&E OPERATIONS, of Estates, Fleet Estates, Fleet, Procurement Deputy Medical 1a) July 1b) July Jun-17 July, Procurement 1. Dec Dec 2016 Risk 3. March Assurance, Estates, Fleet 4. June, Deputy Quality Nursing Ongoing review Workforce survey conducted. Working with Transformation team to review potential rota changes. Consultation process underway, due to be complete by May/June 1b) Clinical Supervision pilots currently in progress in 3 localities Harnesses in process of being distributed - 75% complete. Training video now available on YAS 24/7 Arrangements in place. Follow up audit to be completed. Regular medical equipment testing underway recorded. Asset logging process underway on all equipment. The longer term aim is to have all Meds Man electronically. Audit forms have improved there is now a database system as a live report. POMs process improved. SOP has been amended. 109 new vehicles equipment rolled out across Trust. SOP completed communicated. Ongoing monitoring of compliance to SOP activity. 1. Key messages disseminated following inspection 2. All practice issues have been addressed through local feedback training 3. Works completed on priority issues. Other actions included in routine estates maintenance plan. 4. Training commissioned started in Q4 of 16/17 - Board Trust Management Group training completed May 1. Bright Ideas relaunched December Process working well, with improved feedback on ideas implemented. 2. Early discussions pilots have started regarding embedding Quality Improvement methodology. 3. Recruitment to A&E management structure complete. 4. Freedom to Speak Up Guardian role in place - annual review due in July Staff in post skillmix vs plan ACQI indicators Mealbreak shift overrun indicator Safe staffing indicator I4I visit reports I for I visit reports 1. I4I visit reports 2. data capture reporting Controlled drug audit process Medicines Management Internal Audit report I4I report Activity of bariatric support vehicles s Follow up fire risk assessments Fire safety health safety training delivery Feed back from staff Incidents near misses Bright Ideas introduced into practice Staff Feedback on staff manager engagement

3 3.1 Ensuring that at all times there are qualified experienced staff 1. Implement Workforce Plan. 2. Utilise Sub Contractor Framework develop governance arrangements around an inspection framework. OPERATIONS Managing Mar-18 Working up timescales for delivery. 12 month forecast on track. Consultation underway, due to be complete by May/June Staff in post skill mix vs plan indicators Patient staff feedback 3.2 Child seats/harnesses not always accessible on vehicles 3.3 Consistency of cleaning IPC, with daily monitoring for all vehicles 3.4 Arrangements staff time for start of shift vehicle check Training requirements for operational staff relating to vulnerable groups Management of vehicles equipment Consistency of service quality for renal patients 1. To provide vehicles with suitable child harness when required. 1. Ensure all staff complete start of shift checks on PDA. 2. Ensure all staff clean vehicle after every journey 3. Continue with deep cleaning regime. 4. Implement a system for T/L's to routinely monitor cleanliness of all vehicles 1. Ensure all staff complete the 1st user check on PDA 1. Review implement new training plan -18 Directof 1. Continue with the regular safety check regime 2. Implement monitor a robust process from vehicle being reported with defect to repair 3. Ensure robust process for securing monitoring the storage of oxygen cylinders on vehicles. 4. Review implement a stard loadlist for vehicles Finance 1. Continue to implement revised operational processes 2. Maintain improved engagement with renal patients processes to ensure timely feedback on any quality issues Managing / Managing / Managing Managing, Training Estate, Fleet Estate, Fleet Estate, Fleet, Procurement Managing Jun-17 July Monthly monitoring vehicles to be issued with ACR systems when reclaimed from A&E. Harnesses to be kept on station. Vehicle cleanliness reminder on the PDA device. Local TLs carrying out spot checks of vehicles throughout the day. Audit plan developed by Lead Nurse for IPC. New Team Leader job descriptions will include compliance monitoring. Team huddles will be used raise awareness - pilots in 3 areas under way. All staff have 15 minutes to complete vehicle check pre start of shift. Data collection needs to be improved. I4I visit reports T/L ride along KPIS monitored through Group I for I visit reports 01/03/ Vehicle check completion data Jun-17 Work has started on training needs analysis New training curriculum in place Attendance rates, staff feedback April Benchmarking with other services in progress. Communication education of staff underway. Regular safety testing taking place. Process reviewed revised guidance in operation The list has been agreed through Group is now in operation Following problems experienced as a result of service changes introduced during 2016, the quality of service has been restored processes for ensuring effective engagement with renal patients have been improved. I4I report Arrival collection KPIs for renal patients Patient feedback

4 3.8 CQC findings Consistency clarity of management processes 1. Implement management restructure 2. Develop SOP to strengthen understing of line management escalation processes 3. Implement leadership management development aligned to transformation prog. 4. Implement programme to support development of service improvement skills active engagement of patients staff in service improvement 5. Active programme of engagement with Critical Friends Network, YAS Forum, Healthwatch other patient representative groups to support service improvement. 5. Implement staff communications plan 6. Implement accessible sharepoint site for staff 7. Ensure governance systems are fully embedded to support delivery of a safe, high quality service 8. Implement updated plan to support wellbeing of staff, including focus on musculo-skeletal injury f.,.,., 9. Review Business Continuity plans test 10. Improve rigour of process for capturing monitoring risks mitigations Managing, Communications 1. June 2. July 3. July 4. Sept 5. Sept 6. June 7. Sept Managing, Deputy of April Managing, deputy of, Deputy Apr-17 Managing Sep-17 Managing, Risk Assurance 1. Restructure plans in place, currently at consultation stage. 2. Guidance issued to staff. Further work on communication escalation to be aligned to new A&E structures. 3. programmes will be informed by the new structure an anlysis of individual requirements within the team. 4. staff involved in new safety huddle pilots. 5. Critical Friends Network established programme to be agreed. Discussions with Healthwatch planned for Q1. group in place with ToRs sting agenda covering key aspects of safety, quality workforce. Quality team representation. Renal Coordinator now in place. Focus on patient hospital relations /18 CQUIN includes staff wellbeing. Deep dive to investigate the root causes completed BC ISO has been re accredited. To be reassessed in September focussing on sub-contractors. Due 01/09/ Support provided by Risk Manager. Risks reviewed at monthly Group meeting Delivery of management restructure Delivery of targeted management/leadership development support Feedback from managers Group agenda. Assurance reports to CGG Quality Committee Monthly Ops performance review Reduction in MSK injuries associated sickness absence Flu vaccination rate Successful ISO reassessment Independent review of comprehensiveness of risk register

5 Ensuring that at all times there are qualified experienced staff (including Staff communication engagement 1. Implement EOC recruitment training plan 1. Complete appointment of senior management team 2. Ensure sustained management presence in York control room. EOC Delivery Delivery milestones 1. May 2. COMPLETE - quarterly review 1. Recruitment training plan updated during Q4 2016/ Accelerated recruitment for Call hlers in progress 1. Recruitment to new senior management roles in progress 2. Senior Managers spend 20% of working week at York call centre. SDM role based in York. Staff in post skillmix against plan EOC performance indicators 4.3 Delivery of key training to all relevant staff 1. Refresh training needs analysis for all staff 2. Implement revised training plan to ensure delivery of key requirements including BLS training for all staff. Delivery 01/03/ 1. Training needs reviewed updated. 2. BLS has been delivered on the EOC away days the action plan was completed in December. Training delivery against plan Ensure consistent access to clinical advisors for call hlers Management leadership support for call hlers. Maintain processes systems which enable staff to safely raise concerns Ensure staff are protected from bullying or harassment Support staff in accessing relevant information 1. Review clinical staffing levels clinical staff structure 2. Implement Trust clinical recruitment retention project 1. Undergo review of structure. 2. Review face to face feedback on performance/1-2-1 s 1. Implement ways to help staff to safely raise concerns 1. Review management structure management training. 2. Conduct direct staff engagement exercise to review staff experiences following improvements implemented in 2016/17 1. Review staff training work with Corporate communications to disseminate information NHS 111 NHS 111/ Deputy Human Rersources NHS 111/ NHS 111/ Sep-17 Apr /03/ 2. Oct 1. April NHS 111/ Deputy NHS 111/ 2. October 01/03/ 1. Recruitment project in place since Sept Increased uptake of advertising in early. 'Home working' introduced. YAS will be an early adopter of NHS111/Urgent Care National Career FW. 2. Trust wide group now established to address recruitment challenge. Successful in obtaining NHS Engl Investment Fund money for a 4 month trial - Optimal Supervision Model (additional Team Leaders). 1. Freedom to Speak Up comms in NHS 111 completed. Freedom to Speak Up advocate taken up position. Datix refresh training planned. ACAS involvement, plan in place. Professional Leadership analysis completed with management team. New leadership structure in place for NHS111 to lead on implementation of YAS Behavioural Framework. Most reported cases have been investigated closed. Most of the management team have completed internal EO training. SOP in place. Additional commmunications delivered to staff. Relevant information included in corporate training Improved clinical staffing against establishment Proportion of cases referred to clinician on access to clinicians External evaluation will be undertaken once trial concludes Issues highlighted via FTSU Staff survey Staff survey via engagement exercise Training delivery against plan Staff survey other staff feedback 6.1 Maintain develop good practice in comm control Review comm escalation process Resilience Head of Resilience Jul-17 Work progressing in line with plan. Completed review Implementation of actions arising KEY Must Do Should do Other issues highlighted