11 PAM system 11/02/2015

2 At a high level the NHS PAM is based on two types of analysis. 1.Qualitative, self-assessment of effectiveness, safety and patient experience - Self Assessment Questions, and; 2.Quantitative, benchmarking against the NHS organisations peers across four Domains (ERIC, HES, PLACE). The Self Assessment Questions represent what the NHS organisation does (input), while the Metrics represent how well the NHS organisation is delivering (output). Comparison of these shows how well assurance is being provided, while identifying areas of strength and weakness. What is the NHS PAM?

3 The NHS PAM is a management tool, designed to provide a nationally consistent approach to evaluating NHS premises performance against a set of common indicators. It delivers a basis for: assurance on the premises in which NHS healthcare is delivered; driving premises-related performance improvements throughout the system; providing greater understanding of the vital role that NHS premises play in the delivery of improved clinical and social outcomes. It is designed to be used locally by NHS organisations for Board reporting, and externally to provide assurance to Regulators and Commissioners. What is NHS PAM?

4 Governance/transparency

5 PAM strategic overview Letters to CEO’s/Directors of Facilities 28/07/11David Flory, Deputy NHS Chief Executive Highlights the publication of ‘A Universal version of the NHS Premises Assurance Model (PAM)’. 24/01/13David Flory, Deputy NHS Chief Executive Launch of PAM 13 the purpose of this letter is to advise you an updated and revised version of the NHS PAM is being released for NHS Providers to use as a basis for locally derived Estates & Facilities assurance for Boards. 19/05/14NHS EstatesPAM 14 launched 06/06/14Dr Dan Poulter MP, Parliamentary under Secretary of State for Health The NHS PAM has been updated to support trust boards in ensuring that their estates and facilities management services are safe, effective and efficiently provided. Its use should be at the heart of providing assurance in this area and, as a benchmarked tool, driving efficiency improvement. The Model aligns with the post-Francis regulatory requirements, in particular the Care Quality Commission inspection process, and support the focus on patient safety and efficiency. The model also aims to support Monitor’s and the TDA’s strategic planning frameworks.

6 PAM - background The 2014 version of NHS PAM is the third main iteration of the model. The main changes are: Consistent with changes to regulatory and inspection requirements Incorporate soft FM services Respond to user feedback Capture changes to any dataset e.g. replacement of PLACE with PEAT Consistent questioning User feedback Cost to compliance Permits site and organisation wide assessments

7 PAM structure and content The NHS PAM has two distinct but complimentary parts: Self assessment questions (SAQs) supporting quality and safety compliance Metrics: supporting efficient use of the estate The NHS PAM SAQs have five Domains: Efficiency (formerly Finance & VFM) Safety Effectiveness Patient Experience Organisational Governance The Organisational Governance domain is a strategic domain that brings together the four other domains and ensures they are reported and acted on appropriately by the Board.

8 PAM structure and content Each domain has a set of Self Assessment Questions (SAQs) with a sub set of questions known as prompt questions. It is the prompt questions that are scored/rated with due regard to the information contained within the following two columns in the PAM: Relevant guidance and legislation: Policies, procedures, working practises etc. should comply with any relevant guidance and legislation. Evidence should demonstrate: The approach (policies, procedures etc.) is understood, operationally applied, adequately recorded, reported on, audited and reviewed. There is no requirement to include evidence within PAM - the free text cells within PAM allow users to cross refer to where evidence is available if requested during inspections etc.

9 PAM 2014 question set DomainTotal Number of SAQs Total Number of Prompt questions Organisational Governance748 Safety27243 Patient Experience749 Effectiveness636 Efficiency537

Safety domain (SAQ’s) Safe and compliant with well managed systems in relation to: S1. Asset management and maintenanceS15. Fire Safety S2. The design and layout of premisesS16. Waste Management S3. Health and safety at workS17. Cleanliness and infection control applying to premises and facilities S4. in respect of catering servicesS18. Laundry and linen services S5. AsbestosS19. Medical devices and equipment S6. Medical gas systemsS20. Security management S7. Natural gas and other non medical piped gas systemsS21. Resilience, emergency and contingency planning S8. Water systemsS22. Transport services S9. Electrical systemsS23. Pest control S10. Mechanical systems e.g. lifting equipmentS24. Premises and equipment issues identified in all relevant safety-related reporting systems. S11. Ventilation systemsS25. Contractor management S12. LiftsS26. Undertaking new build and refurbishment works S13. Pressure systemsS27. Safety and suitability of premises and services, when the organisation is not responsible for the premises S14. Decontamination processes

Prompt questions - can the organisation evidence the following: Enter the presentation's title using the menu option View > Header and Footer Prompt Policy and proceduresDoes the organisation have a current approved policy and an underpinning set of procedures? Roles and responsibilities Does the organisation have formally appointed people with clear descriptions of their role and responsibility which are well understood. Statutory requirements and guidelines Has there been a review of all relevant statutory requirements and guidance and a risk assessment undertaken. Asset RegisterHave all relevant assets been identified and records kept in an appropriate manner? TrainingDoes the organisation have an up to date training plan in place covering all relevant roles and responsibilities of staff, that meets all safety and quality requirements? Building and maintenance work Where building and maintenance work impacts on existing systems are risks assessments undertaken and the work designed, undertaken and commissioned to the appropriate standards. Resilience, emergency and contingency planning Does the organisation have resilience, emergency, contingency and escalation plans which have been formulated and tested with the appropriately trained staff? Review ProcessIs there a robust annual review process to assure compliance and effectiveness of relevant standards, policies and procedures? Action PlansIf the organisation is not fully compliant in this area, are there risk assessed action plans in place to ensure compliance?

12 Enter the presentation's title using the menu option View > Header and Footer SAQ 1 - Asset management and maintenance Prompt QuestionsSuggested evidenceGuidance 1.Policy and procedures 2.Roles and responsibilities 3.Statutory requirements and guidelines 4.Asset Register 5.Training 6.Building and maintenance work 7.Resilience, emergency and contingency planning 8.Review Process 9.Action Plans 1.Documentary evidence relevant to the prompt questions e.g. evidence of policy and procedures 2.Preventative/corrective maintenance strategies 3.Demonstration of re-investment of income 4.Maintenance system 5.Evidence of planned preventative maintenance 6.Sufficient regular corrective and preventative maintenance funding in capital investment strategy 1.Health Building Note 00-08: Estatecode 2.Health building Note 00-08: Land and property appraisal 3.A risk-based methodology for establishing and managing backlog (NHS Estates 2004) 4.Establishing and managing backlog (NHS Estates 2004)

13 SAQ 9 - electrical systems Enter the presentation's title using the menu option View > Header and Footer Prompt QuestionsSuggested evidenceGuidance 1.Policy and procedures 2.Roles and responsibilities 3.Statutory requirements and guidelines 4.Asset Register 5.Training 6.Building and maintenance work 7.Resilience, emergency and contingency planning 8.Review Process 9.Action Plans 1.Documentary evidence relevant to the prompt questions e.g. evidence of policy and procedures - that relevant regulations are: - understood by all teams involved - applied by all teams involved - systematically checked for compliance - reported for exceptions 2.Copies of test certificates/EC Declarations of conformity 3.Records of inspections/thorough examinations 4.Copies of insurance certificates/formal documentation from notified bodies 5.Written schemes of examination 1.Electricity at Work Regulations 1989 (EAWR) 2.Health Technical Memorandum : Electrical Services/Safety 3.HTM 00: Policy and Principles of Healthcare Engineering

14 There are six possible responses for a prompt question: -Not applicable: this prompt question does not apply to your organisation/site. -Outstanding: compliant with no action plus evidence of high quality services and innovation. -Good: compliant no action required. -Requires minimal improvement: the impact on people who use services, visitors or staff is low. -Requires moderate improvement: the impact on people who use services, visitors or staff is medium. -Inadequate: action is required quickly - the impact on people who use services, visitors or staff is high. -Not applicable Scoring

15 Resources Gov.UK: assurance-model-launchhttps:// assurance-model-launch PAM 2014 PAM practical guide PAM metrics SAQ’s DH guidance Health building note Strategic framework for the efficient management of healthcare estates and facilities HEFMA working group Linked in - NHS Premises Assurance Model (PAM) Discussion GroupNHS Premises Assurance Model (PAM) Discussion Group Enter the presentation's title using the menu option View > Header and Footer

16 WSFT experience 11/02/2015

Enter the presentation's title using the menu option View > Header and Footer

18 Action plan Total No. of actions 49: Finance and value for money - 6 Safety - 24 Effectiveness - 15 Patient experience - 4 Board governance - 0 On-going monitoring of the action plan will be undertaken by the Corporate Risk Committee, with an annual update to the Board of Directors. Enter the presentation's title using the menu option View > Header and Footer

19 Example output (2013 version) Enter the presentation's title using the menu option View > Header and Footer Fully compliant and significant exemplar evidence available Fully compliantPartial compliance None or minimal compliance

20 Example output (2014 version) Enter the presentation's title using the menu option View > Header and Footer

21 Example output safety domain Enter the presentation's title using the menu option View > Header and Footer