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Streamlining Facilities Compliance & Implementation: A Case Study from The Chesterfield Royal Hospital

Explore the journey of implementing a proactive Facilities Compliance & PAM strategy in a hospital setting. Learn about the challenges faced, innovative solutions implemented, and key lessons learned for successful compliance management.

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Streamlining Facilities Compliance & Implementation: A Case Study from The Chesterfield Royal Hospital

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  1. Facilities Compliance & Implementation of PAM The Chesterfield Royal Hospitals Journey Chris Tann Associate Director of Estates and Facilities

  2. Compliance(PAM) Yearly Return or the Day Job?

  3. Original Approach to Compliance • Different Approach for each Compliance Specialty. • No Consistency in Reporting. • Lack of Risk Based Approach. • No Audit Process. • No Devolvement of Responsibilities.

  4. Standardising our Approach • Formation of Statutory Working Groups for each Compliance Speciality. • Develop Standard Questions and Format. • Devolve Responsibilities to Lead Engineers.

  5. RESULT – Engineer Action Overload Develop Team Competencies Develop Policies Appoint Responsible Persons Ensure Adequate Records Develop Contingency Plans Review PPM Monitor Project Compliance

  6. Embedding Compliance into the “Day Job” • Formed Dedicated Team to Monitor Compliance and Facilitate Statutory Working Groups. • Up-skill Team Members to Enable Responsibilities and Actions to be Devolved. • All Actions Risk Rated and Prioritised. • Compliance Team Ensure all Actions are Allocated to Responsible Persons and Deadlines Monitored. • Facilities Compliance Committee Chaired by Director of Facilities Reviews Progress on Monthly Basis.

  7. Dashboard

  8. Standard Questions - 13 sets of questions - asked at each meeting

  9. RAG Table Key Colours for: Risk Assessment Guide

  10. Actions Log • -Risk Scores • -Actions • -Meeting Notes • -Deadlines

  11. Out Look Tasks (Sent via email)

  12. Summary of Meeting

  13. Template Flow Chart

  14. Certificate of Appointment Letter Template

  15. Evidence Examples: - Guidance docs - Policies - Procedures - Assets - Certificates

  16. Dashboard

  17. Overview Summary

  18. Dashboard

  19. Pie Chart Summary

  20. Dashboard

  21. Summary of Task Progress

  22. Dashboard From the dashboard the scores from the working groups are then exported directly into the PAM spreadsheet

  23. Safety Domain 2014/2015

  24. Safety Domain 2015/2016

  25. Key Lessons Learned • Standardised Approach (Statutory Working Groups). • Dedicated Compliance Resource. • Development of Team and Appoint Responsible persons. • Report and Escalation to Compliance Committee. • External Support and Independent Verification.

  26. Support and advice • Professional Organisations e.g. IHEEM/FEFMA • Inter Trust Networking. • External Support

  27. Thanks for Listening Any Questions

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