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PAM system

11/02/2015

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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?

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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?

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Governance/transparency

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PAM strategic overview

Letters to CEO’s/Directors of Facilities28/07/11 David Flory, Deputy NHS

Chief ExecutiveHighlights the publication of ‘A Universal version of the NHS Premises Assurance Model (PAM)’.

24/01/13 David 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.

19/05/14 NHS Estates PAM 14 launched

06/06/14 Dr 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.

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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

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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.

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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.

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PAM 2014 question set

Domain Total Number of SAQs

Total Number of Prompt questions

Organisational Governance 7 48

Safety 27 243

Patient Experience 7 49

Effectiveness 6 36

Efficiency 5 37

Safety domain (SAQ’s)Safe and compliant with well managed systems in relation to:

S1. Asset management and maintenance S15. Fire Safety

S2. The design and layout of premises S16. Waste Management

S3. Health and safety at work S17. Cleanliness and infection control applying to premises and facilities

S4. in respect of catering services S18. Laundry and linen services

S5. Asbestos S19. Medical devices and equipment

S6. Medical gas systems S20. Security management

S7. Natural gas and other non medical piped gas systems S21. Resilience, emergency and contingency planning

S8. Water systems S22. Transport services

S9. Electrical systems S23. Pest control

S10. Mechanical systems e.g. lifting equipment S24. Premises and equipment issues identified in all relevant safety-related reporting systems.

S11. Ventilation systems S25. Contractor management

S12. Lifts S26. Undertaking new build and refurbishment works

S13. Pressure systems S27. 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:

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Prompt

Policy and procedures Does 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 Register Have all relevant assets been identified and records kept in an appropriate manner?

Training Does 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 Process Is there a robust annual review process to assure compliance and effectiveness of relevant standards, policies and procedures?

Action Plans If the organisation is not fully compliant in this area, are there risk assessed action plans in place to ensure compliance?

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SAQ 1 - Asset management and maintenance

Prompt Questions Suggested evidence Guidance

1. Policy and procedures 2. Roles and

responsibilities 3. Statutory requirements

and guidelines 4. Asset Register 5. Training6. Building and

maintenance work7. Resilience, emergency

and contingency planning

8. Review Process9. 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 income4. Maintenance system5. Evidence of planned preventative

maintenance6. 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)

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SAQ 9 - electrical systems

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Prompt Questions Suggested evidence Guidance

1. Policy and procedures 2. Roles and

responsibilities 3. Statutory requirements

and guidelines 4. Asset Register 5. Training6. Building and

maintenance work7. Resilience, emergency

and contingency planning

8. Review Process9. 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 examinations4. Copies of insurance certificates/formal

documentation from notified bodies5. Written schemes of examination

1. Electricity at Work Regulations 1989 (EAWR)

2. Health Technical Memorandum 06-01: Electrical Services/Safety

3. HTM 00: Policy and Principles of Healthcare Engineering

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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

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Resources

• Gov.UK:https://www.gov.uk/government/publications/nhs-premises-assurance-model-launch

PAM 2014

PAM practical guide

PAM metrics

SAQ’s

DH guidance• pamhelpdesk@dh.gsi.gov.uk• Health building note 00-08 Strategic framework for the efficient

management of healthcare estates and facilities• HEFMA working group• Linked in - NHS Premises Assurance Model (PAM) Discussion Group

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WSFT experience

11/02/2015

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Premises Assurance Model - WSFT 2014M

onito

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An

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Se

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Ass

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prep

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Ass

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Org

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Trust sign up to PAM process

Identify leads Briefing meetings to explain the

process and what is required

Set up central repository for domain

assessment and evidence

Source and print reference

documents

Review PAM domain and

prompt questions

Leads to review relevant SAQ and supporting

documents and collect evidence

Agree responsibility / timescales for

action plan

Identify evidence discussed at

workshop and collate

Prepare report/presentation

Present at Scrutiny

Committee

Domain workshops x 5

Present at Trust Board

Annual assessment

Present at Corporate Risk

Committee

Complete assessment and

action plan

Agree format and process

Annual update at Trust Board

Corporate Risk Committee

Ongoing monitoring of action plan

Financial implications from action plan

included in business planning cycle

Update/add to Trust risk register where appropriate

Identify specialist experts (medical gas,

decontamination)

Store evidence in central repository

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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.

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Example output (2013 version)

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Fully compliant and significant exemplar evidence available

Fully compliant Partial compliance

None or minimal compliance

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Example output (2014 version)

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Example output safety domain

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