Name: Dianne Conduit
Job Title: Director of Development and Executive Nurse
Organisation: Chesterfield PCT
Email: mailto:dianne.conduit@chesterfieldpct.nhs.uk
Telephone: 01246 514305
Key team: Eileen Foster - Clinical Risk Manager, Janet Goodwin - Corporate Services Manager
Title: Policy procedure maze - the matrix reloaded
As a legacy of organisational changes and mergers there was no clear way of the PCT ensuring policies, procedures, guidelines and protocols had been adequately developed, consulted on, ratified, disseminated, monitored and reviewed.
It was also clear that frontline staff were confused and not consistently able to implement new procedures because of lack of training and preparation.
The need to change was apparent when the clinical governance team put the following evidence together;
Matrix shared with High Peak and Dales PCT and North Eastern Derbyshire PCT each organisation has adapted and adopted it for their use.Perceived and actual increases in clinical and non-clinical risk, including health and safety issues.
Feedback through staff surveys and other organisational development information.
Difficulties and delays in getting work developed collegiately across organisations in North Derbyshire
Lack of clarity in PCT Board and the Professional Executive Committee (PEC) responsibilities
We hoped to achieve:
The implementation of a systematic process that staff are clear about and by which the PCT can exercise effective controls assurance, enabling all clinical and non-clinical policies, procedures, guidelines and protocols to be developed, appropriately implemented, monitored and reviewed
Staff, the PCT as an organisation, patients, carers and members of the public.
The clinical risk manager and corporate services manager undertook an extensive piece of work reviewing all policies, procedures etc and tracked a significant number through the development, decision making and ratification process.
The review included how and where each type of policy/procedure should go through the organisation. In addition the implementation process including training, monitoring and review systems were analysed.
All the information was brought together and a matrix was devised that clearly demonstrates the way the new system works, including what is ratified and approved where, including those policies and procedures coming into the organisation from outside.
Awareness and training sessions to promote the Matrix have been completed and it continues.
Chairs and members of internal and external clinical and non-clinical groups, the PEC, the Board, managers and clinicians from across the PCT
We knew we had achieved it with the production and implementation of the comprehensive and systematic Matrix system and processes, which the PEC and Board approved
Seeing ‘front sheets’ coming through with all of the relevant information from a wide variety of sources
Staff asking for more information and putting forward ideas to expand and improve the system and processes
The Matrix accepted as a major component of the clinical governance and overall controls assurance systems and processes.
The chaos of finding out how the process worked inside and outside the organisation - or didn’t – careful systematic approach, opening lots of cans of worms and turning over lots of stones!
Finding a way of playing detective and challenging current practise that did not upset staff – having patience, lots of explanations, a sense of humour and demonstrating early ‘quick wins’ of how things would improve
Finding ways of effectively working with clinicians and managers to develop an integrated system with processes that everyone could sign up to from front line clinical staff, middle managers, the Board and the PEC – lots of joint working and the approach outlined above
Bringing clinical and non-clinical risk together to make sense of controls assurance and how clinical governance has an impact on managers and how non-clinical risk has an impact on clinical activity, patients and staff
Clarity within the PCT of how we contribute collegiately but an absolute understanding that decision-making rests with Chesterfield PCT
More defined working by the Board and PEC regarding roles, function and responsibilities.
