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
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 2017. 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 2017. Dr Julie Hall, Executive Directr f Nursing th 10P 2017 Page 2 f 10
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
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
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.
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
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. 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
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
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