North of Scotland Approach to simulated training and assessment in Neonatology and Paediatrics with inclusion of Rural General Hospitals

Transcription

1 NORTH OF SCOTLAND PLANNING GROUP Project Initiation Document North of Scotland Approach to simulated training and assessment in Neonatology and Paediatrics with inclusion of Rural General Hospitals Author: Dr Helen Freeman Date: 04/12/14 Version: \NoSPG Project Initiation Document sim2 dec14[1].docx

2 Contents 1. Document Control Background Key Aims and Objectives [Data audit, benchmark, how this will sit within service in Scotland) Project Scope (and any exclusions) Expected Outcomes Roles and responsibilities Outline Project Plan Project Budget Key Stakeholders and Types of Communication Risk Register Equality & Diversity Impact Assessment Guidelines for Completion of Project Initiation Document Glossary \NoSPG Project Initiation Document sim2 dec14[1].docx

3 Please refer to Section 13 Guidelines for Completion of the Project Initiation Document and Glossary, Section Document Control Key Personnel Title: Author: North of Scotland Approach to simulated training and assessment in Neonatology and Paediatrics with inclusion of Rural General Hospitals Dr Helen Freeman, Dr Deborah Shanks Approver: Owner: Dr Helen Freeman Version History Version Date Summary of changes Initials Changes v1.0 04/12/14 Filename and Path Distribution Name Division Title Board Page 3 of 14

4 2. Background [including a brief and clear description of purpose and history of project current services/ assets, related constraints, current inequalities and drivers for change, baseline evidence, define delivery. Contextual text a rational of why this needs to be done. National exception/drive]. The benefit of simulation training for technical skills, such as theoretical knowledge, procedural skills and technical performance during resuscitation as well as for non technical skills such as teamwork, leadership and communication has been well established in both adult and paediatric critical care. 1 Simulated resuscitation teaching has been shown to improve practitioner confidence, competence and decrease anxiety regarding participation in future critical events. 2,3 Staff at the start of their career and in isolated areas may worry more about neonatal and paediatric resuscitation and regular resuscitation courses are not always attended by relevant staff. The reasons for this are unclear but may include fear of exposure of poor knowledge. Equipment is available for Sim teaching in NHS Highland but lack of staff funding mean this has not been developed to its full potential or extended to remote areas. Ways of exploring need and engaging staff particularly in rural areas need to be explored more. Also development of the VC aspect of supervising care of sick children and resuscitation via VC is an area of training need recognized during the Paediatric unscheduled care (PUC) pilot. Through use of local facilities we have the capacity to develop simulation training of the care of sick children, acute resuscitation and stabilization, and also training in VC supervision of simulated events. Currently we have 3 paediatric consultants and one advanced neonatal nurse practitioner with training in simulation based teaching. One consultant, Dr Freeman, has undertaken a Masterclass in simulation training, with several years experience of helping to run paediatric simulation courses as part of an experienced active simulation faculty. Recently in Raigmore Hospital we have undertaken some in house training scenarios as part of a quality improvement project to develop sepsis management pathways, which have been extremely well received. Initial consultation with the Scottish Centre for simulation and clinical human factors (SCSCHF) paediatric education co-ordinator has indicated clear support for our proposal to develop paediatric simulation training in the North of Scotland. Through liason with the Clinical skills managed educational network, and the RCPCH Assistant Officer for Simulation, we hope to develop local expertise and cascade training. NHS Highland s Clinical Skills Centre provides a potential venue for simulation training. This includes a 4 bed mock ward and a practical skills laboratory which include video conferencing and CCTV recording equipment used for training purposes. Paediatric equipment includes a Gaumard Paediatric and baby HAL mannekins. As part of the Northern Neonatal Network, NHS Highland has recently received a Laerdal Sim NewB to facilitate simulated neonatal resuscitation training. To date opportunities to utilize this resource have been limited by staff capacity to develop this work in Raigmore Hospital and RGHs. The purpose of the faculty development is not to duplicate the work of the North neonatal managed clinical network. This network supplied training for local staff but provides no simulation training in NHS Highland and trained personnel have been unable to utilise their skills. The aim is to develop an experienced local faculty with capacity to support training needs of North of Scotland trainees and facilitate locally delivered training in rural areas through co-ordinated paediatric and neonatal training days to medical, nursing and paramedic staff. Dr Nikolaus Kau, former north neonatal MCN lead, who has driven their simulation programme is supportive of this bid, and has joined our steering and working group to ensure collaboration to strengthen the overall development and provision of simulation training across the region. In addition to local equipment, we have discussed with Professor Jean Scott Ker National Lead for Clinical Skills and Simulation the potential to use the mobile skills unit to assist with delivery of high fidelity simulation training to rural general hospitals with access to Laerdal Sim Junior and Sim baby mannekins and she is very keen that we use her facility to provide more training in rural areas, particularly scenarios on unwell children rather than purely resuscitation eg child with asthma or seizures. There is no overlap of provision as the mobile Page 4 of 14

5 skills unit is a venue which is accessible to faculties with appropriate training to allow them to deliver training locally. The CSMEN/MSU is not funded to provide paediatric training, but rather provides a venue accessible for those wishing to provide training. There is potential to utilise the mobile unit when it is booked in regions to deliver training as requested locally, but also for us to book the unit to deliver a programme of targeted training across north region. Our aims have been discussed with Dr David Rowney, SCSC paediatric education coordinator and Dr Michael Moneypenny, director of the Scottish Centre for Simulation who have expressed their support. The Royal College of Paediatrics and Child Health (RCPCH) advocates for the delivery of simulation based training in all schools of paediatrics in order to ensure equity of access to resources for all trainees and to promote multidisciplinary simulation-based education. The RCPCH strategy on simulation and technology enhanced education notes that it needs to be locally led,clinically driven, patient centred and flexible. The Royal College of Anaesthetics has made their Simulation course mandatory for their Specialist trainees and this is something that could be developed for North of Scotland paediatric trainees moving form ST2 to ST3 level. 4 We have discussed this proposal with Dr Elma Stephen, training programme director for northern region, who has expressed clear support,and joined our steering group so we can look at develop simulation training for trainees in line with the RCPCH curriculum. It would be the purpose of this project to develop expertise by creating a Faculty for Paediatric Simulation teaching in the North of Scotland based in NHS Highland/Argyll and Bute to explore service need in Highland, Argyll and Bute and Grampian along with their associated Rural general Hospitals by scoping staff needs. This would involve visiting all the centres, setting up a service model in Highland and disseminating learning to all centres. An initial step would be to link with the clinical skills managed educational network paediatric education lead to develop local programmes in line with national drivers to ensure collaboration and sharing of resources and skills. 1 Stocker et al, Impact of an embedded Simulation team training programme in a paediatric intensive care unit: a prospective single centre longitudinal study. Intensive care Medicine 38: Langham et al, Simulation-based training in critical resuscitation procedures improves residents competences. CJEM 11: Allan et al, Simulation based training delivered directly to the pediatric cardiac care unit engenders preparedness, comfort and decreases anxiety among multidisciplinary resuscitation teams. J thoracic cardiovascular surgery 140: Royal College of Paediatrics and Child Health, Simulation and TEL strategy, accessed online 23/09/2014: %20strategy.pdf 3. Key Aims and Objectives [Data audit, benchmark, how this will sit within service in Scotland). The key aim of the project is to: Provide clinical time for medical and nursing staff to set up a Simulation Faculty to initially map learning needs in the North of Scotland region to sites where neonates and children are resuscitated and then develop scenarios and deliver simulation teaching. (see exceptions in scope below) Objectives: Scope learning needs of staff in Orkney, Shetland, Inverness, Fort William, Caithness, Argyll and Bute and Skye. (There is also potential to include Western Isles if they would like to be included.) This will include telephone/vc interviews and questionnaires to assess attitudes to Sim teaching and local staff and equipment needs. Page 5 of 14

6 Establish Sim scenarios ( 3 consultants and 1 ANNP already trained) including VC remote supervision of sick children and focusing on recognition and stabilisation of sick children and infants, and crisis resource aspects of teamworking as training scenarios. Scenarios can be tailored to local requirements as determined during scoping phase. Incorporate Sim sessions into regular hospital teaching for nursing, midwifery, paramedic and medical staff in Raigmore Hospital Explore potential increased use of the Mobile Skills Unit in Remote areas. Develop training programme and recommendations for service development throughout the North of Scotland, and work collaboratively with the NoS neonatal MCN Evaluate programme and provide written summary of findings and recommendations to Health Boards. Explore development of curriculum based simulation for trainees in paediatrics across region. Outputs Project needs in addition to Activities above: Liason with clinical skills MCN to develop collaboration in scenario and course development. In line with RCPCH recommendations, seek feedback and external evaluation of simulation teaching to allow critical appraisal and development. Each Health Board will have a responsibility to develop a strategy for Simulation training in Paediatrics at the end of the project. Highland faculty scenarios could be used by all Health Boards, and the NHS Highland faculty could be contracted to supply this teaching across the North of Scotland. Simulation courses particularly for competencies could be run in NHS Highland and be funded by the separate Health Boards for trainees. 4. Project Scope (and any exclusions) The scope of this review is focussed on (particular services or Health Boards). This will include: Simulation training in neonates and children in North of Scotland region based in NHS Highland with particular remit to Rural General Hospitals including NHS Orkney and NHS Shetland. NHS Western Isles are supplied by RHSC Glasgow out of hours, but have been invited to participate. (NHS Tayside has simulation trainers providing in situ training to local staff in Ninewells Hospital and has therefore not been included in the scope at present.) However, discussion with Linda Clerihew has indicated support for collaboration in faculty and scenario development) Development of simulation faculty across region to facilitate simulation training both in situ and on designated courses. 5. Expected Outcomes (as per logic model diagram/implementation plan, Level 1 Appendix 1, list outcomes) An evidence based approach to Simulation training in the care of sick children and resuscitation Improved recognition and acute management of sick child/neonate with more equity of patient care across all centres in the North of Scotland Improved multidisciplinary team-working in the acute environment through focus on both medical management and human factors. Page 6 of 14

7 Improved patient safety through staff training, and testing of systems. Better use of available modern technology to enhance learning including VC facilities Exit strategy involves trainers skills being maintained through regularly teaching on courses and funding for staff time made available through charging for courses locally, running courses for other boards and job planning process in NHS Highland to allow time. This is supported by local management. Regional faculty and scenario development through collaboration between centres. Development of paediatric simulation training tailored to paediatric trainee curricula in north region in line with RCPCH strategy. 6. Roles and responsibilities (see Glossary for a description of terms dependant on Projects) Project Sponsor Project Lead Dr Deborah Shanks, Service lead for Children s Health Services, NHS Highland Project Manager Richard Bennie, Manager of Children s Health Services, NHS Highland Clinical Lead Dr Helen Freeman, Consultant Paediatrician, Raigmore Hospital Steering Group Dr Shanks ( NHS Highland), Dr Freeman (NHS Highland), Richard Bennie ( NHS Highland), Dr N Kau (NHS Grampian), Dr R Diggle ( NHS Shetland), Dr W Nel (MacKinnon Memorial Hospital, NHS Highland), Dr Elma Stephen ( NHS Grampian), Dr J Bennebroek ( MacKinnon Memorial Hospital, NHS Highand) Mairi Stewart ANNP ( NHS Highland), Gillian Haggarty APNP ( NHS Highland), Dr Claudia Rettberg ( NHS Western Isles). Work Team Dr H Freeman, Dr N Kau, Mairi Stewart ANNP, Gillian Haggarty APNP, Dr A.Hosenie, Dr T.Reddy, A.Carr 7. Outline Project Plan Summary of major milestones and/or attachment of Gantt chart at Appendix 2 1 st 3 months Set up Team/Faculty and give roles. Link with the clinical skills managed educational network. Scope Need using structured telephone interviews and develop evaluation strategy. 2 nd 3 months Develop scenarios and establish first training courses in Raigmore Hospital for medical, nursing and paramedic staff, both in situ, and through clinical skills facilities. Collaboration with established simulation programmes in NHS Tayside and simulation trainers in NHS Grampian, and collaborate with NoS Neonatal MCN simulation programme to develop programme of complementary training across region. Develop scenarios for paediatric trainees in line with curricula. Page 7 of 14

8 3 rd 3 months Start running training courses in Rural General Hospitals throughout North of Scotland incorporating use of Mobile Skills Unit where possible. 4 th 3 months Continue to run courses aiming to have reached every RGH and evaluate learning. 8. Project Budget 1 Medical PA (1 year) 11, wte Paediatric Nurse Practitioner or Band 6 nurse 7,958 (in Highland) 0.2 wte Advanced Neonatal Nurse Practitioner 9580 (Highland) Technical support 2,000 Travel & accommodation 5,000 Visiting faculty expenses 1,000 Administrative support 2,000 Total 38, Key Stakeholders and Types of Communication Key Stakeholders Dr Willem Nel Dr Roger Diggle Dr Nikolaus Kau Dr Elma Stephen Role/ Title Rural Practictioner, MacKinnon Memorial Hospital, Skye Medical Director, NHS Shetland Consultant Neonatologist, NHS Grampian Training Programme Director Paediatrics, North Region Type Of Communication Skye clinicians keen to be involved, and Dr Nel agreed to participate in steering group. Planned communication through , telephone, vc and face to face meetings Enthusiastic support for project and has indicated potential interest to contributing to continuing costs as per exit strategy in longer term. Agreed to join steering group. Planned communication through , telephone, vc and face to face meetings Keen to promote collaboration across region and to develop simulation expertise. Has joined steering and working group to ensure close links with neonatal north MCN simulation training. Planned communication through , telephone, vc and face to face meetings Dr Stephen has expressed support for proposal noting development of simulation training in line with RCPCH strategy, and joined our steering group. Planned communication through , telephone, vc and face to face meetings Dr Amalia Mayo Consultant Paediatrician Invited to join steering group as lead for paediatric simulation in NHS Grampian. Response awaited. Page 8 of 14

9 Key Stakeholders Dr Linda Clerihew Dr Claudia Rettberg Role/ Title Consultant Paediatrician Consultant paediatrician NHS Western Isles Type Of Communication Discussion recognising that NHS Tayside has an active in-situ sim training programme in paediatrics, and a different geography to patient services such that less need for scoping and training programme as proposed. However, Dr Clerihew has expressed support for prospect of collaboration between centres in faculty and scenario development which would include NHS Tayside. Communication through telephone and . Keen to be involved, agreed to participate in steering group. Planned communication through , telephone, vc and face to face meetings. Dr Marthinus Roos Medical Director, NHS Orkney Invited to comment/participate. Response awaited Dr David Rowney Scottish Centre for Simulation Paediatric Education coordinator Discussions noting clear support for proposals outlined here, and support of the SCSC in faculty development and collaboration within and between regions. Planned communication through , telephone, vc and face to face meetings 10. Risk Register To be completed following agreement to proceed. 11. Equality & Diversity Impact Assessment To be completed following agreement to proceed Page 9 of 14

10 12. Guidelines for Completion of Project Initiation Document Following Approval The PID becomes a working document and should be maintained and monitored. A comprehensive risk register, all levels of the Logic Model (to ensure the project is monitored and evaluated), detailed project/work plan and equality & diversity impact assessment should also be developed and reported against to NoSPG. Templates and guidance on these processes can be sought from the NoSPG team. 13. Glossary Clinical Lead The Clinical Lead is ultimately responsible for delivering the project successfully in their area of expertise (in this case Clinical) in line with the measurement criteria detailed in the Project Initiation Document. The Clinical Lead manages on a day-to-day basis, all aspects of the project in their area including human resources, tasks, plans, budgets, risks, issues and change. The Clinical Lead is responsible (in their area) for the consistent use of the standard processes used to identify, track and resolve issues, risks and changes. This includes the meeting structures to allow one-to-one sessions with their Work Team members and attendance at the Project Board / Steering Group meeting as and when requested by the Project Manager. The Clinical Lead will ensure that the project plan and budget for their area are updated regularly and meaningful and measurable reports are produced before each performance meeting with the Project Manager. Proposals for resolution of issues relating to Clinical areas including budget, the time line and risks likely to affect the project (including external influences) will be prepared by the Clinical Lead and presented alongside the performance report to the Project Manager. Equality & Diversity Impart Assessment The purpose of impact assessment is to improve patient access, treatment and experience by ensuring that: a) there is no discrimination in the way that services are designed, developed or delivered b) any necessary favourable treatment to take account of disabilities is considered and built in c) opportunities to promote equality are recognised and taken. Impact assessment supports a systematic and explicit consideration of the above, and by recording that consideration and any relevant changes or recommendations for change, provides the required evidence and audit trail. By ensuring that the needs of the whole population are considered, more responsive services can result. Equality & Diversity Impact Assessment is a legislative requirement and completed assessments should be made available to the public. Therefore when completed they should be placed on the NoSPG website. A template and further guidance is available G:\NOSPG\Dundee\NoSPG\Templates\2012 revisions\equality & Diversity Logic Model Please refer to the following documents for guidance and templates which can be found at G:\NOSPG\Dundee\NoSPG\Templates\Project Management\2012 revisions\logic Model: Page 10 of 14

11 A Toolkit to support the Development of a Needs and Evidence Based Approach to the NoS National Delivery Plan for Specialist Children s Services ; and Evaluating NoS Specialist Children s Services, The Application of Logic Models Project Lead The Project Lead is the senior manager within NoSPG who has responsibility for ensuring the project is completed. The Project Manager will report progress and is accountable to the Project Lead. Project Manager The Project Manager (PM) is ultimately responsible for delivering the project successfully in line with the measurement criteria detailed in the Project Initiation Document. The PM manages on a day-to-day basis, all aspects of the project including human resources, tasks, plans, budgets, risks, issues and change. The PM is responsible for the introduction and consistent use of the standard processes designed to identify, track and resolve issues, risks and changes. This includes the meeting structures to allow one-to-one sessions with Project Leads, one-to-all meetings with the project team and at least one meeting per month with the Steering Group. The PM will ensure that the project plan and budget are updated regularly and meaningful and measurable reports are produced before each Project Board / Steering Group meeting. Proposals for resolution of issues relating to the project in general, the budget, the time line and risks likely to affect the project (including external influences) will be prepared by the PM and presented alongside the monthly performance report. Project Sponsor Depending on the size of the project this role may not be applicable for all projects. The Project Sponsor is identified as the senior manager with most to gain or lose by the success or failure of the project. The Sponsor is the project Champion and is recognised (both internally and externally) as the project figurehead. As such the Sponsor must be able to demonstrate a clear understanding of the project s strategic objectives, success criteria and timeline. The Sponsor chairs the Project Board / Steering Group and will have the casting vote should a vote be required to carry a proposal. The Sponsor focuses on strategy and performance and should provide the project with direction and senior management clout as required. The Sponsor is ultimately responsible for ensuring the project team use agreed, standard processes to identify, track and resolve issues, risks and changes. This will be monitored during regular meetings with the Project Manager and Clinical Lead. In chairing the Project Board / Steering Group meetings, the Sponsor will review the overall project performance, assist in the resolution of issues and risks (both internally and externally) and provide on-going strategic support and guidance to the Project Manager. Risk Register Examples of risk are: Data A number of decisions and assumptions will be made based on the data collected by the teams. This data will not necessarily directly supply answers to the targets and outcomes. Page 11 of 14

12 Resources The key to achieving the objective of this review is to ensure co-operation of the stakeholders. There may be competing priorities for stakeholders which may delay progress. There will be other projects within NoSPG competing for staff resources, which may impact on the timescale that this review can be conducted in. Budget No funding has been identified within Health Boards or NoSPG Steering Group The Project Manager and Clinical Lead will seek guidance and support from a steering group consisting of the Service Manager (Project Sponsor), etc The Steering Group will meet on a regular basis to review progress reports from the Project Manager, ensure an agreed project plan is followed and that risks, issues and changes are being identified and managed effectively. Work Team Work Team members are responsible for carrying out the planned project activities in their area of expertise. The deliverables from these activities should be in line with the measurement criteria detailed in the Project Initiation Document. They are also responsible for identifying, developing and conducting training in their area as required. The work team members are responsible (in their area) for the consistent use of the standard processes designed to identify, track and resolve issues, risks and changes. Attempts should be made to resolve these at source or escalate to the Clinical Lead if a satisfactory solution cannot be identified. The Work Team members will ensure that progress on activities carried out in their area is documented prior to the performance meeting with the Clinical Lead / Project Team Page 12 of 14

13 Moving from Logic Model to Monitoring to Evaluation Appendix 1 Is a Regional Approach Appropriate to Delivering your Clinical Service? (Based on Regional Planning Criteria) Yes No Moving from Identifying Needs and the Evidence-Base to Identifying Outcomes and Impacts LEVEL 1 - LOGIC MODEL Please note population of the level 1 of the model could start at any point of the process shown below (ie need not be sequential) Needs Assessment Evidence-base Resources/ Inputs Activities Outputs Outcomes/Impacts What are the needs of your patients? What is the evidence-base for your service? What resources are required to undertake activities in your service? What activities need to be undertaken to deliver your service? What services need to be delivered to achieve the stated benefits/outcomes for your patients? What benefits and changes should your patients, organisations and communities experience? LEVEL 2 IDENTIFY NEEDS, INPUTS, ACTIVITIES, OUTPUTS AND OUTCOMES Clinical Needs Clinical Resources/Inputs Clinical Activities Clinical Outputs Clinical Outcomes /Impacts Non-Clinical Needs Non-Clinical Resources /Inputs Non-Clinical Activities Non-Clinical Outputs Non-Clinical Outcomes /Impacts LEVEL 3 - MONITORING TO EVALUATION Identifying Key Aims, Objectives and Outcomes Monitoring Inputs, Activities and Outputs Monitoring Outcomes Evaluating Service In considering needs, what are the What systems require to be put What systems require to What do the data on inputs, key aims, objectives and outcomes in place to collect input, be put in place to collect outputs, outcomes tell you to monitor and evaluate within activities and output data across outcome data across your about the success/challenges your service? your service? service? of delivering your service? Evaluating Impacts What has your service Page 13 of 14 achieved and what can be improved?

14 ID Task Name Duration Start Finish Predecessors Resource Name 1st quarter nd quarter rd quarter2012 4th quarter nd quarter 3rd quarter 4th quarter Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Workforce Develop a regional workforce strategy to ensure the Network clinical Status Assessment sustained safe delivery of neonatal care in the North facilitator Completed of Scotland through modernised ways of working, On Track to complete by agreed date creative models of service delivery and regional Will be achieved but likely to be delayed collaborative working. 5 yr plan Jan-12 Dec-17 1,2,3,4 All staff Will not be met or is unlikely to be met 1 Meet clinical leads and managers to discuss identified 3 months Jan-12 Mar-12 network leads gaps for individual Boards. 2 Hold a workforce planning workshop with all stakeholders5 months Apr-12 Sep-12 1 stakeholders to identify solutions. 3 Establish workforce project board to take forward 5months Oct-12 Mar-13 1,2 Wf board solutions from workshop. 4 Manage operational and cultural change collaborativley. Apr-13 Dec-17 1,2,3 managers and staff Start five year workforce plan Appendix2 Education Develop regional standardised education programmes E&T subgroup inclusive of all neonatal staff across the network.to ensure patient safety and equity of quality. Take forward the work of the education and training subgroup of the neonatal steering group 24months Jan-12 Dec-13 1,2,3,4,5,6,7 staff and E&T group 1 Scope current education provision. 3months Jan-12 Mar-12 2 Carry out a training needs analysis across the region. 5 months Jan-12 May-12 3 Develop a regional programme. 4months Jul-12 Oct-12 1,2 4 Develop an implementation plan and audit framework. 4months Jul-12 Oct-12 1,2,3 5 Deliver programme. 12 months Oct-12 Oct-13 6 Audit programme. 3months Oct-13 Dec-13 7 Review training across region. Jan-14 Review 2014 Care Pathways Develop clear care pathways for Neonatal care in Network clinical the north of Scotland. lead On-going work Take forward work of service development subgroup of Neonatal steering group on-going Jan-12 on-going 1 Develop first 4 pathways ensuring clear communication 6months Jan-12 Jun-12 Service development structure and guidance is available. subgroup 2 Develop regional clinical forum. 3months Apr-12 Jun-12 3 Review first draft of pathways against Quality framework. 6months Apr-12 Oct-12 1,2 4 Neonatal steering group to sign off pathways for 3months Oct-12 Dec-12 1,2,3 implementation. 5 Standardise policies, procedures and clinical guidelines on-going Jan-12 Dec-12 on-going review where appropriate. on-going work Transport Develop collaborative working agreements, pathways and guidelines with the Scottish Neonatal transport service, the Scottish Ambulance Service and the Neonatal Network. 1 Hold discussions with the Service development 8months Jan-12 Sep-12 subgroup of the Neonatal steering group and SNTS and SAS to develop pathways and identify roles and responsibility during the transfer process. 2 Review pathways at regional clinical forum. 3months Sep-12 Nov-12 1,2 3 Sign off agreements and pathways at neonatal steering 1month Dec-12 Dec-12 group. 4 Implement across region through clear communication. 3months Jan-13 Mar-13 1,2,3 network clinical lead SNTS& SAS Page 14 of 14