Staff Governance Self Assessment Audit Tool
for NHSScotland employers
2002/03
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FOREWORD
The NHSScotland Staff Governance Standard was launched in January 2002. It was developed by a partnership of management, trades unions and professional organisations through the Scottish Partnership Forum (SPF). It introduced the third component of governance, alongside financial and clinical governance, to complete the governance framework within which NHS Organisations are required to operate.
The aim of the Standard is to improve the way staff are treated in NHSScotland, to be clear on what staff should expect wherever they are in Scotland and to improve accountability for making this happen. This will be achieved by focusing on how staff are managed and how they feel they are managed. NHS Trusts, NHS Boards and Special Health Boards are expected to carry out a staff survey and complete this Self Assessment Audit Tool (SAAT). The SAAT has been developed and approved by the Scottish Partnership Forum,
the Clinical Standards Board for Scotland, Clinical Negligence Other Risks Indemnity Scheme (CNORIS) and Audit Scotland.
Improved accountability will be achieved through the independent assessment of the SAAT by the appointed external auditors, in partnership with the SPF, as well as through the Performance Assessment Framework (PAF) process. Action plans produced from the first staff survey and SAAT are required to be submitted for the 2002/03 round of accountability reviews that will begin in May 2003.
The self assessment process requires evidence to support findings and proposed actions. This evidence will include policies and procedures and statistical information on level of turnover, use of temporary contracts, medical census information, etc.
External auditors together with a SPF member will be expected to validate the action plans of Trusts and Boards and provide independent assurance that:
the self assessment process is robust
the action plan is agreed and is credible
the action plan is being delivered (year-on-year).
Members of the SPF working with auditors is an important part of this process as it will enable us to utilise our complementary skills and experience.
NHS Trusts, NHS Boards and Special Health Boards are required to submit to the Scottish Executive a copy of the action plan, along with the auditors report summarising their findings as part of their accountability reviews. This completes the cycle of review.
We believe that the Self Assessment Audit Tool will establish itself quickly as a key component in delivering reform in NHSScotland.
We would be delighted to receive your comments and suggestions about how it could be improved in future.
| | |
Mark Butler
Joint Chair
Scottish Partnership Forum | Michael Fuller
Joint Chair Scottish Partnership Forum | Barbara Hurst
Director of Health & Community Care
Audit Scotland |
A. WELL INFORMED
Leadership arrangements, at all levels, will ensure all staff have regular dialogue and communication and the opportunity to feed back on organisational issues.
All staff receive information about their organisation at regular intervals.
All staff have access to communication systems including electronic mail and will be provided with appropriate training.
Prompt & Task | Response |
A.1 We make sure we communicate effectively with our employees. Check that organisational values have been agreed and for evidence that they are an integral part of the culture. Check for communication strategies which ensure that employees understand: What the NHS organisation wants to achieve What its priorities are How well (badly) it is doing What it wants to do better
Check how the effectiveness of these arrangements is assessed. | A.1 |
A.2 We make sure we listen to our employees. Check that communication arrangements are two-way and that the NHS employer understands the employee view on: What the organisation is trying to achieve What employee priorities and concerns are What the organisation could do better
| A.2 |
A.3 We make effective use of technology. Check what arrangements are in place: | A.3 |
Mandatory Statistical Information NIL |
B. APPROPRIATELY TRAINED
Organisations will implement the Education, Training and Lifelong Learning Strategy Learning Together.
There will be equity of access to training irrespective of working arrangements or profession.
Resources including time and funding will be allocated to meet the training and development needs identified locally.
Mandatory Statistical Information |
C. INVOLVED IN DECISIONS WHICH AFFECT THEM
All staff have the opportunity to be involved in planning and development decisions which affect them.
A framework for partnership working including local and area partnership forums will exist to enable staff involvement through their trade union/professional organisation representatives.
Service developments will be planned in partnership with full consideration to workforce issues which will be costed and included as standard practice.
Prompt & Task | Response |
C.1 We have leaders at all levels who, in partnership, take responsibility for ensuring that staff involvement is developed, regularly reviewed and progress has been made. Check for a systematic approach to involving staff through their trade union/professional organisation representatives. | C.1 |
C.2 All employees are involved in (i.e., have the opportunity to contribute and influence) service planning and, as a result, patient care benefits. Check for a systematic approach to service planning.
Identify specific examples where this has contributed to significant improvement for patients. | C.2 |
C.3 By being involved our employees are motivated and committed to the achievement of agreed service and patient care objectives. Check for evidence of motivation and commitment. Identify/ensure plans are in place to act on signs of demotivation/lack of commitment. | C.3 |
Mandatory Statistical Information |
D. TREATED FAIRLY AND CONSISTENTLY
NHSScotland will be an exemplar employer with best practice human resources policies and procedures in use.
Employees within NHSScotland will be treated fairly and consistently with PIN Guidelines being exceeded or met wherever they work in the service.
Staff within NHSScotland can expect security of employment throughout the modernisation agenda and organisational change.
Prompt & Task | Response |
D.1 PIN Guidelines and best practice policies are developed by area and local partnership forums with the full involvement and support of staff through their trade union/professional organisation representatives. Check for a systematic approach to developing good practice guidelines as they become available from the PIN Board. | D.1 |
D.2 We have up-to-date corporate procedures or guidelines for departments/functions recruiting employees. Check that procedures/guidelines are available and that they include: | D.2 |
D.3 We take appropriate action across the organisation to manage turnover. Check for regular monitoring and reporting of employee turnover including: By grade By department/function
By different turnover measures Check that the key factors affecting turnover are known i.e. whether such turnover is: Pay-related Linked to career development opportunities Linked to employee morale and motivation Check for systems to capture this information i.e. exit interviews, staff surveys.
| D.3 |
D.4 Where it is necessary to reduce employee numbers we ensure this is done in partnership giving full consideration to job security, salary protection and individuals' developmental choices. Check for systematic reviews and partnership approach where numbers are to be reduced. | D.4 |
D.5 We implement collective agreements through appropriate local forums in accordance with agreed processes and timescales. Check for a systematic approach to, for example: | D.5 |
Mandatory Statistical Information |
E. PROVIDED WITH AN IMPROVED AND SAFE WORKING ENVIRONMENT
Organisations will implement the Occupation Health and Safety Services Strategy Towards a Safer, Healthier Workplace.
Resources including time and funding will be allocated to meet the Health and Safety Strategy agreed and audited annually by the local Health and Safety Committee/Board or Partnership Forum. These resources will be applied on an equitable basis irrespective of working arrangements or profession.
NHS premises will be fit for purpose and the personal safety of patients and employees will be paramount in the design and operation of the service.
Prompt & Task | Response |
E.1 We have a health and safety strategy in place, which was developed in partnership. Check for a systematic approach to the development and review of a comprehensive health and safety strategy. | E.1 |
E.2 We are committed to ensuring the wellbeing of our people and we have ensured resources are available to support this. Check for a health and safety action plan which includes resources to support employee wellbeing. Check for progress against Scotland's Health At Work award scheme. | E.2 |
E.3 We have a clear understanding of the Health and Safety issues faced by our people. Check that risk assessments are carried out and the results shared with staff and joint initiatives to eliminate risks are in place. | E.3 |
E.4 We are undertaking benchmarking in relation to accidents/near misses, staff absence, violent and aggressive assault and needlestick injuries. Check that the Occupational Health and Safety minimum data set is being collected, benchmarked, circulated and acted upon. Check for progress in achieving Clinical Negligence and Other Risk Indemnity Scheme (CNORIS) level 1. | E.4 |
E.5 We are committed to ensuring our working arrangements do not cause harm to our people. Check implementation of the Working Time Regulations and local monitoring arrangements. | E.5 |
Mandatory Statistical Information |
CHECKLIST
The following checklist is provided to support organisations in the collection of evidence required as part of the self assessment process.
Communication Strategy and any Supporting Documentation e.g. Staff Newsletter, Team Brief, etc.
Health and Safety Strategy/Action Plan
Induction Programme and Attendance Records
Learning Plans/Strategy
Organisation Values
Partnership Forum Constitution and Minutes
Personal Development Plan Process
PIN Guideline Policies, Awareness and Training
Recruitment & Selection Policy/Procedure
Risk Assessment Procedure
Service Planning Arrangements/Groups e.g. Joint Future Remits, Membership and Minutes
Staff Survey Results and Action Plans
Workforce Plan/Strategy