BOARD OF DIRECTORS. Trust Quality Governance Structure Review

Transcription

1 P March BOARD OF DIRECTORS th Thursday 30P 2017 Trust Quality Gvernance Structure Review Intrductin The purpse f this paper is t utline fr the Trust Bard the nward Quality Gvernance Structure. At the request f the CEO a review f the Trust Gvernance Structure has been undertaken. This has invlved reviewing the subcmmittees that fall under the Quality see appendix 1, and their varius subgrups t ensure they are fit fr purpse t deliver the Trusts Quality Strategy. Furthermre the Trust is required t make CIPs t the value f 17.5m (4.5%) ver the next tw years and it has been agreed that the ttal gvernance functin will make a cntributin t this. sequently it is an pprtunity t refresh and refcus gvernance activity. A primary driver hwever has been the will t reduce the likelihd f failures in standards f care, particularly in relatin maintaining essential stances. The structure itself is primarily an underpinning and shuld be cnsidered alngside regulatry requirements, planned revisins t data in the refresh f internal reprting and the intended culture and capability prgramme. Bard members are asked t cnsider and apprve the revised structure. Quality Structure The frmal meeting infrastructure which supprts the Quality t deliver its terms f reference has been reviewed; this includes its sub-cmmittees and their supprting grups. A number f these have been revised, discntinued r replaced. The main change has been t increase versight f patient experience and plicy cmpliance, and t prpse the underpinning divisinal gvernance structures. The divisinal gvernance structures will be equal unless there is a required exceptin. The verarching gvernance structure and Divisinal Gvernance structure is attached as appendix 1, appendix 2 suggests chairs and the purpse f each subcmmittee and appendix 3 includes the revised terms f reference fr the Quality. There will be six subcmmittees f the Quality, all f which will have Directr r Assciate Directr chairs. Patient Experience and Service Imprvement Health, Safety, Security & Emergency Preparedness Clinical Effectiveness Trustwide Strategic Safeguarding Infectin Cntrl Trust CIRCLE A review f the subcmmittee terms f reference and divisinal grups has been cmpleted. Fr all subcmmittees and supprting grups a mapping exercise is currently underway t define what their key data requirements are fr mnitring quality and cmpliance and nward reprting. This includes: Page 1 f 10

2 P March Cmpliance with CQC regulatins Plicy cmpliance BAF risks Surces f benchmarking infrmatin Cmpliance with Single Oversight Framewrk metrics Internal reprts Data surces and data quality All the terms f reference have been subject t cnsultatin and are ready fr implementatin in April The structure was apprved at the March 2017 Quality and changes agreed at that pint have been included. The Quality were able t scrutinise the terms f reference fr the subcmmittee structure. There will be refreshed reprting in place frm all subcmmittees at the July Quality. Recmmendatins The Trust Bard is asked t: Apprve the Revised Quality Terms f Reference. Discuss and apprve the revised cmmittee structure, and implementatin frm April Dr Julie Hall, Executive Directr f Nursing th 10P 2017 Page 2 f 10

3 Overarching Quality Structure Quality Appendix 1 Bard Assurance Framewrk Patient Experience and Service Imprvement Health, Safety Security & Emergency Preparedness Clinical Effectiveness Trustwide Strategic Safeguarding Infectin Cntrl Trust CIRCLE Service Imprvement & Invlvement Patient Experience & Cmplaints Recvery Strategy Medical Devices Manual Handling Advisry Medicines Optimisatin Research Gvernance Trust Physical Healthcare Steering Audit/Clinical Cmpliance Dmestic Vilence & Abuse Learning & Imprvement & Quality Assurance Think Family Suicide & Self Harm Mrtality Review Vilence Reductin Ulysses Oversight Nte: Physical Healthcare includes respnsibility fr tissue viability, resuscitatin and DNAR, Falls Recvery Strategy includes Vlunteering and Carers Strategy CPA Mnitring is via Audit/Clinical Cmpliance, Medicines Optimisatin includes medicines safety Recrds Management ECT & Neurmdulati n Frum Page 3 f 10 Serius Incident Review Serius Case Review/Dme stic Hmicide Review

4 DIVISIONAL GOVERNANCE STRUCTURES Quality Bard Assurance Framewrk Patient Experience and Service Imprvement Health, Safety Security & Emergency Preparedness Clinical Effectiveness Trustwide Strategic Safeguarding Infectin Cntrl Trust Circle Divisinal Quality Gvernance Divisinal Risk Register Mnitring Divisinal Patient Experience, Imprvement & Invlvement Divisinal Health, Safety, Security & Emergency Preparedn ess Nte High Secure Security reprts directly t the Bard f Directrs Divisinal Research & Audit Trust Physical Healthcare Steering Divisinal Physical Healthcare Steering Divisinal Safeguarding Frum Divisinal Infectin Preventin & Cntrl Divisinal CIRCLE Nte: Divisinal Health Safety, Security & EP includes Medical Devices Page 4 f 10

5 Quality Structure Appendix 2 cmmittee Frequency Chair Purpse Patient Experience & Service Imprvement Health, Safety, Security & Emergency Preparedness Clinical Effectiveness Trustwide Strategic Safeguarding Infectin Preventin & Cntrl Bi-Mnthly Bi-mnthly Bi-mnthly. Bi-mnthly Quarterly Executive Directr f Nursing Executive Directr f Nursing Executive Medical Directr Assciate Directr f Safeguarding Assciate Directr f Nursing designated Trust CIRCLE Mnthly Executive Medical Directr T ensure accuntable and rbust prcesses fr patient experience, imprving experience, wrking in partnership and service imprvement. Leads the measures t ensure the health & safety at wrk f all persns wh may be affected by the business f Nttinghamshire Healthcare NHS Fundatin Trust. Includes the gvernance and leadership f security and emergency preparedness, resilience and respnse. The Clinical Effectiveness - has been established t supprt the develpment and implementatin f the Quality Strategy. The purpse f the is t prvide assurance t the Quality f the Bard that rbust Safeguarding arrangements are in place thrughut the Trust and are wrking effectively. Aims t lead meeting the current standards in Infectin Preventin and Cntrl, and ensuring sufficient designated persnnel, clear respnsibilities, adequate lines f cmmunicatin and ther resurces t facilitate the effect f preventin, detectin and cntrl f infectin. The subcmmittee prvides a trustwide framewrk t identify risks t patient safety and measure imprvements, crprate versight t the reprting, management, and learning frm incidents, steers the mrtality surveillance framewrk and leads the implementatin f the Sign up t Safety Campaign.

6 Appendix 3 QUALITY COMMITTEE TERMS OF REFERENCE 1. Cnstitutin The Nttinghamshire Healthcare NHS Fundatin Trust hereby reslves t establish a cmmittee f the Bard f Directrs (hereafter referred t as the Bard ), t be knwn as the Quality (hereafter referred t as the ). 2. Purpse The purpse f the cmmittee is thrugh a strategic apprach, t maintain versight and undertake scrutiny in rder t infrm the Bard f the level f assurance identified that rbust quality gvernance arrangements are in place thrughut the Trust and that these are wrking effectively. 3. Membership The shall cmprise: 3 Nn-Executive Directrs (nne f whm shall be the Chair f the Audit r the Trust Chair). A Nn-Executive Directr will chair the cmmittee (in the absence f the Chair, anther Nn-Executive Directr will chair the cmmittee). Executive Directr: Nursing Executive Directr: Frensic Services ExecutiveDirectr: Health Partnerships Executive Medical Directr Directr f Human Resurces Assciate Directr fr Quality Gvernance Assciate Directrs f Nursing A deputy shall be nminated t attend a meeting f the cmmittee when the absence f ne f the members (detailed abve) wuld prevent an item f business being addressed. The deputy attending shall cunt twards meeting qurum, but nt t the attendance recrd f the cmmittee member him / herself. All members shall attend a minimum f 4 ut f 6 meetings f the cmmittee n a rlling 12 mnth basis. 6

7 4. Qurum Qurum shall be 4 members t include 2 Nn-Executive Directrs and 2 Executive Directrs. 5. Attendance at Meetings A standing invitatin t attend the Quality will be extended t the fllwing: Chief Executive Trust Chair (will bserve the at least nce per annum) Other Nn-Executive Directrs representatives f Internal and External Audit Others will be invited t attend the cmmittee as deemed necessary and dependent upn the matters fr cnsideratin. Representatives f the Cuncil f Gvernrs may attend meetings f the cmmittee in an bservatry capacity. The secretary t the cmmittee shall be the Cmpany Secretary with administrative supprt prvided by the Cmpany Secretary s ffice. 6. Meetings The cmmittee shall meet a minimum f 6 times per annum. Additinal ad hc meetings may be cnvened as and when required. 7. Authrity The cmmittee is authrised by the Bard t: Prvide verriding strategic directin and guidance t facilitate the develpment and implementatin f rbust quality gvernance arrangements thrughut the Trust, aligned t the Care Quality Cmmissin dmains. Assess n an nging basis the level f assurance that the abve arrangements are effective The cmmittee shall wrk in liaisn with the Trust s Audit, Finance & Perfrmance, Wrkfrce, Equality & Diversity and Mental Health Legislatin cmmittees t ensure the prvisin f timely and apprpriate assurance t the Bard, recgnising the interface between the rles and remits f these cmmittees. 7

8 8. Duties T maintain a strategic versight f quality gvernance envirnment and cntext in which the Trust perates and assciated risks. T infrm the Bard f the level f assessed assurance with regard t quality gvernance arrangements acrss the Trust. T mnitr and review the Trust s Quality Strategy and Quality Pririties, implementatin theref and the prductin f the Trust s Quality Reprt, prviding assurance t the Bard. T mnitr, review and assess the level f assurance received n the quality risks, cntrl and gvernance prcesses identified in the Bard Assurance Framewrk delegated t the cmmittee by the Bard, prviding reprts t the Bard f Directrs and / r Audit as requested. T mnitr and review the Trust s cre strategies assciated with the cmmittee`s remit e.g. Medicines Management. T receive the Trust Annual CPA (Care Prgramme Apprach Reprt). T mnitr and assess the level f assurance received n the quality impact f Cst Imprvement Prgrammes. T assess the level f assurance received with regard t cmpliance f the Trust s quality plicies and systems with regulatry, legal and cde f cnduct requirements. T mnitr the implementatin f agreed Internal Audit review recmmendatins relating t the cmmittee s remit. Maintain nging review thse risks detailed n the Trust`s Bard Assurance Framewrk fr which the cmmittee is the designated respnsible cmmittee. T mnitr n-ging cmpliance with CQC Outcmes and implementatin f agreed actins fllwing CQC inspectins / visits. T prmte learning and sharing fr all areas f activity, bth frm within and utside f the Trust, including benchmarking with areas f recgnised best practice. 8

9 T review the reprting sub-cmmittee structure t ensure bth efficiency and effectiveness f reprting, including the establishment f new cmmittees r wrking grups as required. T review and apprve annually the terms f reference and wrk plans f reprting sub-cmmittees / grups, mnitr their activities and assurances and cnsider issues escalated by them. The cmmittee will direct the relevant sub-cmmittees t undertake deep dive reviews f specific issues in rder t gain apprpriate assurance. Reprts will be received frm each f the -s including key metrics Patient Experience & Service Imprvement -cmmittee Health, Safety, Security and Emergency Preparedness cmmittee Infectin Cntrl -cmmittee Trust wide Strategic Safeguarding -cmmittee Trust-wide CIRCLE Clinical Effectiveness -cmmittee and frm bth Divisinal Quality Gvernance s: T develp and maintain an annual wrk-plan t reflect and enable scrutiny and assurance in relatin t matters within the cmmittee s remit. Thrugh the Chair and Executive spnsr(s), ensure that apprpriate cmmunicatins are maintained with regard t the activity f the ther Bard cmmittees. T escalate issues f cncern requiring Bard awareness and r attentin. Undertake tasks assigned t the by the Bard. 9. Reprting Prcedures Minutes f all meetings f the cmmittee will be prduced and frmally ratified at the fllwing meeting. A written summary each meeting shall be submitted t the next scheduled meetings f the Bard and the Audit. In additin, an annual reprt will be prduced by the Cmpany Secretary s ffice setting ut the cmmittee s cmpliance with its terms f reference, perfrmance f its duties and strategic pririties fr the next 12 mnths. The reprt will be infrmed by an annual self-assessment cnducted by the cmmittee, ensuring its wrk and 9

10 respnsibilities are reflective f the changing envirnment within which the cmmittee functins. 10. Review These terms f reference will be reviewed n an annual basis by the t ensure they remain fit fr purpse and be submitted t the Bard fr frmal ratificatin. 11. Ratificatin: Ratified by: Nttinghamshire Healthcare NHS Fundatin Trust - Bard f Directrs Date: 10