board assurance and escalation framework · 4. risk escalation process 5. board governance...
TRANSCRIPT
CONTENTS
1.0 Introduction
2.0 Definition of Quality
3.0 Purpose
4.0 Culture
5.0 Staff involvement
6.0 Patients/carers/public involvement
7.0 Internal and external sources of assessment/assurance
8.0 Commissioners and NHS Midlands and East
9.0 Trust‟s Internal Performance and Quality Monitoring
10.0 Decision-making and escalation
11.0 Trust‟s Risk Monitoring Escalation and Assurance framework
12.0 Committee Structures
13.0 Monitoring of action plans
14.0 Organisational learning
Appendices
1. Integrated Planning, Performance and Risk Management framework
2. Information flows to support decision-making and assurance process
3. Risk Management Structure
4. Risk Escalation Process
5. Board Governance Structure
6. Role and Function of Key Committees
7. Governance & Quality Committee sub-groups
8. CQC Escalation Process
9. Quality Improvement Process
10. Quality Account Process
11. Cost Improvement Plan Process
Version control:
Author: Mandy Edwards, FT Project Manager
Version 10.0 Draft Document 7th
May 2012
1. Introduction
Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has developed a range
of policies, systems and processes which, when drawn together, comprise a robust
governance structure which provides a framework for the assurance and escalation of quality
within the Trust.
This document describes this assurance and escalation framework and demonstrates how
the Trust‟s quality systems and learning from events is monitored by an effective committee
structure. It also illustrates how this process links to Monitor‟s Quality Governance
requirements which are structured around the four pillars; strategy, capability and culture,
processes and structures and measurement.
This provides the Board with assurance about how the organisation is able to identify,
monitor, escalate and manage quality concerns in a timely fashion and at an appropriate
level.
2. Definition of Quality
The Trust‟s Quality Improvement Strategy describes quality by reference to „High Quality
Care for All‟ published in June 2008 and the government white paper, „Equity and
Excellence: Liberating the NHS‟ which states that quality should be at the heart of the NHS.
To bring clarity to quality, the Trust has developed a clear definition of quality and quality
governance using the three dimensions of quality defined in „High Quality Care for All‟. It also
reflects Monitor‟s definition of quality governance as being the combination of structures and
processes at and below board level to lead on trust-wide quality performance.
The National Quality Board‟s paper „Quality Governance in the NHS – A guide for provider
Boards” uses Monitor‟s quality governance framework to provide clarity to Boards and acts
as a „route map‟ to support Boards to deliver improved quality and outcomes and this has
been used as a key document to support the quality journey.
3. Purpose
This framework describes the Trust‟s quality governance structure, systems and
performance indicators through which the Trust Board receives assurance. It also describes
the process for the escalation of concerns or risks which could threaten delivery of the
Trust‟s quality objectives, service delivery or patient safety. The Trust‟s overall integrated
planning, performance and risk management framework is set out in Appendix 1.
4. Culture
The Trust has an open, honest and learning culture, which is described in its
“Whistleblowing” policy. The Trust encourages the reporting of all adverse incidents by its
staff and the reporting of complaints and concerns by patients, their carers and relatives.
5. Staff Involvement
The Trust has a number of policies and systems which encourage staff at all levels to be
involved in performance monitoring and to raise concerns about any risk issues. These
include:
„Whistleblowing‟ and „Being Open‟ policy
HR Policies
Safeguarding Policies (Children and vulnerable adults)
Staff Surveys
„Ask Gary‟
"Hear Me" telephone hotline for staff
Staff Partnership Forum
Risk Management Strategy
Risk Management Policy
Serious Incidents Requiring Investigation (SIRI) Policy
Incident Policy
Quality Improvement Strategy and Quality Matters Framework
Aggregating Data and Learning from Incidents, Serious Untoward Incidents,
Complaints and Claims Process
The incident, near-miss and serious untoward incident policy
The complaints policy
CQC/NHSLA compliance against standards (including self-assessments)
Information Governance policies and processes
Appraisals and Performance Development Process
Monthly Performance meetings for Service Lines and quarterly performance
review meetings for Heads of Service
6. Patients/Carers/Public Involvement
The Trust has a Board approved Service Experience Strategy that includes a
comprehensive implementation plan, which has been developed to address both national
and local drivers. The Trust encourages patients and/or their carers and the public to make
comments and/or raise concerns both formally and informally via a number of mechanisms,
such as:
Compliments
Patient and carer experience surveys
Patient Stories
Patient Experience Tracker Tools
LINks (Local Involvement Networks)
Local Authority – Health Overview and Scrutiny Committee
Service Experience Desk which includes Patient Advice and Liaison Service (PALS)
and Complaints, both formal and informal
Service User and Carer forum
Stakeholder Forum
Patient Environment Assessment Team (PEAT)
Ward Representatives
Patient Advocacy
Experts By Experience (EBE)
The Trust positively engages with patients and/or their carers and the public and welcomes
their involvement and feedback on how they can become better involved in the Trust‟s
decision making process.
7. Internal & External Sources of Assessment/Assurance
Internal and external sources of assessment/assurance cover the range of the Trust‟s
activities and include:
Audit Commission (review of Quality Account)
Internal Audit (review of internal systems and processes)
Commissioner Appreciative Enquiries
Specialty reviews (e.g. Care Quality Commission)
National Audits (e.g. Diabetes, Falls)
Independent Reviews (e.g. Ombudsman reports)
Network reviews (e.g. QIPP)
Patient and carer experience surveys
Patient Stories
Patient Experience Tracker Tools
LINks (Local Involvement Networks)
Local Authority – Health Overview and Scrutiny Committee
Service Experience Desk which includes Patient Advice and Liaison Service (PALS)
and Complaints, both formal and informal
Service User and Carer forum
Stakeholder Forum
Mental Health Act Scrutiny Committee
Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations
Accreditation for Inpatient Mental Health Services (AIMS)
Electro Convulsive Therapy Accreditation Service (ECTAS)
Safe Effective Quality Occupational Health Service (SEQOHS) accreditation
Code of Hygiene compliance
Patient Environment Action Team (PEAT) assessments
West Midlands Quality Review Service
NHS Litigation Authority (NHSLA) Compliance
Information Governance Toolkit
Audit Commission National Benchmarking club
Cost Improvement Plan (CIP) and Service Transformation Quality Impact
Assessments (QIA)
The Trust also commissions external reviews of its activities/services where the need for
additional independent assessment/assurance is identified.
8. Commissioners & NHS Midlands And East
In addition to the internal routes for raising concerns and risk, there are formal mechanisms
by which the commissioners and strategic health authority can raise concerns. These
include:
Board to Board meetings (NHS Midlands and East)
CRM - Contract Review Meeting (Commissioners)
CQM - Clinical Quality Meeting (Commissioners)
Provider Management Regime (PMR) for aspirant Foundation Trusts
GP Concerns
SUI Process
Patient Safety Incidents reported via NRLS (National Patient Safety Agency reporting
and learning system)
West Midlands Quality Review
Mental Health Programme Board
SHA Quality & Safety Review of aspirant Foundation Trusts
9. Trust’s Internal Quality and Performance Monitoring
9.1. The Trust has a number of forums where performance and quality are discussed, and
these are detailed in Appendix 2. The key performance meetings are the contract
activity review meeting (CARM) held monthly, corporate finance & performance
committee (F&P) held monthly, governance & quality committee (G&Q) held monthly
and service performance reviews held quarterly.
The service performance review meetings cover a number of domains focussed
around a set agenda. These cover:
• Service Performance, focusing on:
Access
Demand
Productivity and efficiency
Quality and Safety
Workforce
Finance
Service User/Carer Experience
• Cost Improvement Programme (CIP)
• Contractual requirements e.g. QIPP and CQUIN
• Service developments
The Contract Activity Review Meetings provide the opportunity to feed into the
corporate Finance and Performance Committee meeting, supported by
comprehensive, RAG-rated dashboards to inform discussion. Reporting of key issues
adversely affecting performance is done on an exception basis, and any key risks or
areas of performance requiring escalation are brought to the fortnightly Management
Executive Team meetings to be managed accordingly.
The Governance and Quality Committee receive performance information and
intelligence relating to all aspects of governance, quality, safety, patient experience,
risk and regulation. Reporting is on an exception basis and any key risks or issues are
reported through to Trust Board.
9.2. Desktop Performance Dashboard
A desktop performance dashboard has been in place since Q2 2011, which details a
range of performance and quality indicators with the most recent day‟s, week‟s or
month‟s performance against target, on a RAG-rated basis. Data in the warehouse is
refreshed every day, and so provides almost real time performance information. Each
KPI in the dashboard drills down to team and patient level to identify breaches in a few
clicks. The dashboard enables monitoring of internal, external (local and national)
KPI‟s and data quality/completeness indicators.
9.3. Integrated Performance Report
An integrated performance report has been in place since Q3 2011, which details a
range of indicators with their most recent month‟s performance against target, on a
RAG-rated basis. The content of the report is reviewed regularly and covers those
areas of performance and quality that have been reported through the escalation
process and/or which are subject to scrutiny by commissioners. The report is reported
monthly to CARM and F&P Committee.
9.4. Top Level Integrated Performance Dashboard
The Integrated Performance Dashboard and report are reported monthly to the Trust
Board and provide assurance around the Trust‟s performance in relation to a number
of key areas including:
• Monitor‟s Compliance Framework
• NHS Midlands and East Provider Management Regime (PMR)
• Contractual requirements with NHS Dudley & NHS Walsall
• Patient safety and quality
• Key corporate performance indicators
• Data quality
Any areas of adverse performance are reported to the Board based on the monthly
Contract Activity Review Meetings and the monthly corporate Finance & Performance
Committee and Governance & Quality Committee meeting discussions, and include
remedial actions to address issues with a timescale for delivery.
The Governance & Quality Committee is regularly updated on the self assessment
against the Essential Standards, informed of any areas of non-compliance and
provided with assurance that steps are being taken to ensure compliance.
9.5. Management and Monitoring
The integrated performance report is monitored at CARM. Risks and exceptions are
escalated to Management Executive Team (MExT) for remedial action and reported to
Finance and Performance Committee to provide assurance to the Board.
The governance exception report is monitored at Governance & Quality Committee
and risks and exceptions escalated via Management Executive Team (MExT) for
remedial action and reported to Finance and Performance Committee to provide
assurance to the Board (see committee structure at appendix 5& 7).
9.6. Cost Improvement Plans
The Trust has in place a process for the development and monitoring of Cost
Improvement Plans (CIP) which includes the establishment of a robust Project
Initiation Document (PID) for each individual CIP scheme including a Quality Impact
Assessment (QIA). This is described in Appendix 11.
9.7. Quality Strategy and Account
The Trust has in place a Quality Improvement Strategy the implementation of which is
supported by a Quality Matters Framework and annual Quality Improvement Plan. The
delivery of the continuous quality improvement described by the strategy, framework
and plan is underpinned by the Quality Improvement process as set out in Appendix 9.
The Trust‟s annual Quality Account provides a report to the public about the quality of
the services the Trust provides and the progress against its strategic and annual
quality objectives. It gives opportunity for scrutiny on how the Trust performs in
relation to quality and sets out the focussed areas for quality improvement for the
forthcoming year. Assurance is required on the Trust‟s Quality Account from the lead
Commissioner and from the Trust‟s external auditors, the Audit Commission. The
Trust‟s annual Quality Improvement Plan is monitored by the Governance and Quality
Committee. Appendix 10 describes the process for developing, reviewing and
reporting the quality account.
9.8. Service Experience Strategy
A key element of the Trust‟s quality monitoring is listening and responding to feedback
from service users and carers, together with engagement and involvement in the
Trust‟s performance and development. The Service Experience Strategy is central to
delivering high quality, responsive services and identifies three key approaches to
ensure this:
Listen - to people‟s experiences and views
Respond - comprehensively to feedback through investigation and analysis of
feedback, communicating findings & identifying actions
Demonstrate - what has improved as a result, through reporting feedback
demonstrating learning and committing to improvement based on real patient
consultation.
The strategy is underpinned by an effective Service Experience Desk, which collates
and reports on performance in relation to service user experience. Individual reports
for each Service Line are presented quarterly at Service Line Quality meetings. The
information and narrative of this report then forms the basis of the MExT (quarterly),
Governance & Quality Committee (monthly) and Trust Board (6 monthly) reports.
As well as a number of formal forums where service user and carer representatives
are core members e.g. Service User & Carer Forum, Stakeholder Forum, Governance
& Quality Committee, representation is encouraged on operational workstreams and
Trust events such as annual staff awards.
10. Decision Making and Escalation
10.1. Monitoring compliance against Care Quality Commission (CQC) Essential Standards
The Trust undertakes a regular programme of self assessments against the CQC
Essential Standards. This involves the Trust‟s Clinical Governance Facilitator liaising
with Team and Departmental managers to ensure that ongoing compliance is
evidenced via departmental CQC workbooks.
The Governance and Quality Committee receives exception reports on the progress of
self-assessments, and any areas of non-compliance or with compliance concerns. The
exception reports also provide assurance against the steps being taken to ensure
compliance is achieved.
A CQC escalation process has been developed to ensure decisions are made at an
appropriate level to ensure that quality of care and patient safety are guaranteed at
all times (see Appendix 8).
11. Trust’s Risk Monitoring Escalation & Assurance Framework (See Appendix 3)
The Trust operates 5 tiers of risk management (including the Board assurance
Framework) which are all interlinked via an escalation process (Appendix 4). The
escalation of a risk is dependent upon the level of the risk, or on whether it is felt that the
risk needs specialist management at a higher tier, such as the risk requiring a multi
directorate approach to management.
11.1. Local and Directorate Risk Logs/Registers (Tiers 1 – 3)
These are linked to risk assessment, incidents, complaints and SUI‟s.
Corporate and Operational Services have a process in place to keep their risk
registers updated. They provide updates on the content of their risk registers monthly
to the Governance Manager for inclusion into the Trust Wide Risk Register (TWRR)
where appropriate.
Risks are reviewed within a stated time frame by the local teams to ensure that
controls in place are effective, and assess whether the risk changes over time.
Risks may be identified through internal processes e.g. complaints, incidents, claims,
service delivery changes, risk assessments or financial interests. They may also be
identified by external factors e.g. national reports and recommendations.
11.2. Trust Wide Risk Register (TWRR)
Escalation from Directorate Risk Registers of risks scoring more than 15 and
additional risks requiring multi directorate/disciplinary approach.
The Trust Wide Risk Register is the aggregation of the local team risk logs/registers
and directorate risk registers where the residual risk is more than 15. It includes any
additional sources of risk such as external or internal reviews. It is maintained centrally
by the Trust Governance Manager. It identifies the source, describes the risk, scores
and grades it and provides a summary of the action taken to control it. It includes a
review date and a residual risk rating.
11.3. Board Assurance Framework (BAF)
Escalation from TWRR and additional strategic risks scoring more than 16.
The Trust‟s Board Assurance Framework (BAF) underpins the delivery of its key
objectives and incorporates the highest risks faced by the organisation. It therefore
aligns the Trust‟s principal risks with the key controls and assurances for each of the
Trust‟s key objectives. Where gaps in assurances are identified, mitigating actions are
developed to reduce the risk of the non-delivery of these key objectives.
The BAF is reviewed on a quarterly basis by the Trust Board and includes all red
operational risks. The BAF also includes those risks that have been identified as
strategic risks central to the delivery of the Trust‟s core activities. The formation and
development of the BAF is the responsibility of the Director of People and Corporate
Development and is overseen by the Strategic Planning Manager, who provides
advice on strategic risks to the organisation. Strategic risks are identified by the Board
and reviewed quarterly together with the BAF and progress on delivery of corporate
objectives.
The Board Assurance Framework provides a vehicle for the Trust Board to be
assured that the systems, polices and people in place are operating in a way that is
effective and focussed on the key risks which might prevent the Trust objectives
being achieved.
11.4. Management and monitoring of the BAF
Risk is managed at all levels, both up and down the organization. Refer to Risk
Management Strategy for details. (See appendices 3 and 4 for escalation process)
The Board Assurance Framework (BAF) is monitored on a quarterly cycle. In order to
ensure triangulation between the annual plan and the BAF, the Trust produces an
integrated report to the Finance and Performance Committee and to the Trust Board.
Part 1 Performance against objectives (annual plan performance review)
Reports on the progress made against each of the 16 high-level annual
objectives and highlights any KPI‟s or milestones not being met i.e.
triangulation with the performance framework. It concludes with a RAG rating
of the likelihood that the objective will be delivered.
Part 2 Assurances on the management of risks related to achieving objectives (BAF)
Presents the controls and assurances around the principal risks that may
impact the delivery of the annual objectives and, more importantly, the
strategic objectives. Each risk is linked to a Trust objective and has an
Executive lead, responsible for receiving assurance that the actions required to
mitigate the risk are completed at either local operational or strategic level.
12. Committee Structures (See Appendices 5 & 6)
13. Monitoring of Action Plans
The Trust has a robust process of monitoring actions arising from external reviews, internal
audit reports and SUIs and high level assessments which also hold individuals to account to
deliver a number of initiatives (e.g. Service Transformation, Foundation Trust status, CIPs
and corporate objectives).
Various committees are tasked with monitoring these action plans which are part of their
work plans, these include;
Audit Committee: Actions from Internal Audit Reports, Counter Fraud
Governance & Quality Committee: Actions from; CQC, NHSLA, Information
Governance, Clinical Audit, External Quality Reviews (E.g WMQR), C.Difficile,
Norovirus
Finance & Performance Committee: 18 weeks, Occupied Bed days, CIPs, Corporate
Objectives
Foundation Trust Programme Board: FT Action Plans, Membership, TFA
Service Transformation Programme Board: Service Transformation projects, clinical
vacancies, CIPs, ST QIA, service reviews
14. Organisational Learning
The Trust is committed to learning from incidents and complaints in a culture that is open
and transparent, and share this learning across the organisation. This is achieved in a
number of ways;
On-going reporting and analysis of data concerning incidents, serious untoward
incidents, complaints and claims through the Governance Department
Regular reporting of analysis and trends to key Committees and the Trust Board
Regular identification of key learning for professionals and teams
On-going discussion, monitoring and review by the Embedding Lessons Group
Publication of the minutes of the Trust Board (via the Trust Intranet)
Dissemination of minutes of key committees such as the Safeguarding Committee,
the Health and Safety Committee, the Infection Control Committee, the Medicines
Management Committee and the Embedding Lessons Group.
Monthly communication and information sharing through the Commissioner Review
Meetings in Dudley and Walsall.
Communication from the Governance Department detailing lessons learnt through
the Team Brief communication newsletter.
Awareness raising posters and materials via the Governance Department.
Embedding Lessons Folders within clinical teams.
Appendix 1 - Integrated Planning, Performance and Risk Management Framework
Appendix 2 - Information flows to support decision-making and assurance process
Trust Board
Stakeholder Forum
Mental Health Act Scrutiny
Committee
Audit Committee
Finance & Performance Committee
Governance & Quality
Committee
FT Programme
Board
MExT
Service Transformation
Programme Board
Workforce & OD Committee
Contract Activity Review
Meeting
Capital Planning Meeting
Regulation & Risk Working
Group
Embedding Lessons Group
Service Line Governance & Quality Groups
Safeguarding Strategic Group
Information Governance Committee
Service User & Carer
Reference Group
Clinical Audit & Effectiveness Committee
Medicines Management Committee
Health & Safety Committee
Equality & Diversity
Committee
Operational
Financial
Clinical
Trust Board Director
Governance
Performance
Service User/Carer
Workforce
Communications
The diagram is intended to illustrate the
performance, quality and safety information flows
within the Trust which support the decision making
and assurance processes. It is therefore not a
comprehensive organisational structure chart.
The coloured dots indicate the organisational
representation at key forums and thus the multi-
dimensional nature of information flows within the
Trust.
Appendix 3 - Risk Management Structure
Risks are identified at a local level and escalated, depending on score, to the next appropriate level.
Appendix 4 – Risk escalation process
Risks Managed (risk score) Responsibility Tier of risk
Register
Risks that are rated low (Risk Score of 1 – 5)
where it is felt this risk can be managed
locally.
The risk is the responsibility
of the identified owner
(Appropriate Managers,
Team Leaders, head of
department)
Local Risk
Logs (Tier
5)
Risks that are rated medium (Risk Score of 6
– 12) and risks that are rated low (1 – 5)
where it is felt that the risk cannot be
managed locally and requires a multi
departmental approach to the management of
risk.
The risk is the responsibility
of the identified owner
(Appropriate Manager, Team
Leader, Associate Director)
Local Risk
Registers
(Tier 4)
Risks within the Directorate that are rated as a
high risk (15 – 25) where it is felt that the risk
can be managed within the Directorate and
risks that are rated as a medium risk (6 – 12)
where it is felt that the appropriate director
needs to take ownership of the risk.
The risk is the responsibility
of the identified owner (in this
case Director)
Directorate
Risk
Registers
(Tier 3)
There may be risks identified which require committee ownership as well as individuals.
These are assimilated by the Regulation and Risk Working Group and will form part of the
Trust wide risk register and in some instances the Board Assurance Framework, these are
outlined below.
Risks Managed (risk score) Responsibility of
individuals and Committee
Tier of risk
Register
Risks that are rated as a high risk (15 – 25)
and medium risks (6 – 12), that require a
multi-directorate approach to manage the risk.
The risk is the responsibility
of the appropriate Director
and is monitored by the
Trusts Governance and
Quality Committee
Trust Wide
Risk
Register
(Tier 2)
Those risks that have been identified as
strategic risks to the organisation and those
risks identified by the Trusts Governance and
Quality Committee as requiring Trust Board
ownership
The risk is the responsibility
of the Trust Board.
Board
Assurance
Framework
Appendix 5 - Board Governance Structure
*NB – the role of the Charitable Funds Committee is performed for each borough’s
charitable funds via the respective PCT’s Charitable Funds Committee.
The work of the Trust Board and its Committees is underpinned by the work of the
Management Executive Team meeting (MExT) which under the chairmanship of the Chief
Executive oversees the operational functions of the Trust.
TRUST BOARD
Finance &
Performance
Committee
Audit Committee
Governance & Quality
Committee
Mental Health Act
Scrutiny Committee
*Charitable Funds
Committee
Remuneration &
Terms of Service
Committee
Appendix 6 - Role and Function of Key Committees
Board
Sub-
Committee
Membership Frequency Principal Functions from Terms of Reference Committee reports
received
Audit
Committee 3 Non-
Executive Directors
At least
quarterly Review the effectiveness of integrated
governance and internal control across the Trust.
Ensure an effective internal audit function that meets regulatory standards.
Review the work and findings of the appointed external audit function.
Review the findings of other significant assurance functions
Review the financial statements and annual report prior to the Board.
Ensure adequate arrangements for countering fraud and review the outcomes of counter fraud work
None
Finance and
Performance
Committee
3 Non-Executive Directors
Chief Executive
Director of Finance, Estates and IM&T
Monthly Review all aspects of financial management arrangements
Review performance against key operational and contractual targets
Review performance of each locality/ business unit.
Review key financial strategies, policies and plans
Review significant business cases for the development, amendment or cessation of services.
Estates and Capital Planning Group
Contract Activity Review Meeting
Governance
and Quality
Committee
2 Non-Executive Directors
All Executive directors
Associate Directors - Operations
Associate Directors – Medical
Professional Leads
Functional Heads
Service User and Carer reps
Monthly Monitor assessment, compliance, assurances and evidence in support of national evaluations and assessments
Monitor the assessment and compliance against NHSLA and CQC essential standards.
Ensure systematic opportunities for patient, carer and public participation are embedded
Ensure compliance with relevant regulatory, legal and code of conduct requirements.
Lead committee for overseeing development, implementation and monitoring of the Quality Framework and Quality accounts
Monitor external reviews, enquiries, surveys and investigations, and lessons learned.
Monitor service quality and patient experience to ensure action is taken, lessons are learned and disseminated.
Monitor the function and compliance of the risk management policy, principles and assurance framework.
Health and Safety Committee
Infection Control Committee
Information Governance group
Policies and Procedures group
Service User and Carer Reference group
Clinical Audit and Effectiveness group
R&D group
Medicines Management Committee
Equality and Diversity group
Safeguarding group
Board
Sub-
Committee
Membership Frequency Principal Functions from Terms of Reference Committee reports
received
Mental Health
Act Scrutiny
Committee
2 Non-Executive Directors
Mental Health Act Administration Leads
Director of People and Corporate Development
At least
quarterly To ensure that the Trust meets all of its
requirements under the Mental Health Act.
To be responsible for the development, review and implementation of Mental Health Act policies and procedure to support compliance with legislation.
To ensure that recommendations made in response to the Mental Health Act Commission (MHAC) reports are actioned appropriately.
To monitor the role and performance of the Associate Lay Managers under the Act.
To review and monitor the use of the Act within the Trust, noting and further investigating any trends with respect to locality, gender, age, ethnicity and cultural background.
None
Remuneration
& Terms of
Service
Committee
Chair and 2 Non-Executive Directors
≥1 per
annum, as
required
Set and review the terms and conditions of Board-level directors (except Non-Executive Directors)
Monitor and evaluate the performance of Board-level Directors (excluding Non-Executive Directors)
Authorise any non-contractual payments for all employees.
None
Charitable
Funds
Committee
The role of the Charitable Funds Committee is performed for each localities charitable funds via
the respective PCT‟s Charitable Funds Committee.
Whilst MExT is not a formal sub-committee of the Board it performs a valuable operational
role and for completeness its membership, functions and the committee reports it receives
are shown below:
Committee Membership Frequency Principal Functions from Terms of
Reference
Committee
reports received
Management
Executive Team
(MExT)
All Executive directors.
Associate Directors - Operations
Associate Directors – Medical
Professional Leads
Functional Heads
Fortnightly Act as the main „operational board‟ of the Trust, making decisions that ensure the effective implementation of Trust strategy, monitoring outcomes and providing assurance of progress.
Monitor the work of the Locality Management Meetings and Acute Care Forum.
Receive and agree formal business cases to deliver strategic plans.
To act as the main forum within which the interface of clinical and non-clinical services is addressed.
OD & workforce
Service Transformation
Community Operational Management Meeting
DONs
Business Opportunities Team
Quality Performance Review meetings
Appendix 7 - Governance & Quality Committee – sub groups
Trust Board
Governance & Quality
Committee
Safeguarding Strategic Group
Information Governance Group
Research & Development
Group
Policies & Procedures Focus
Group
Service User & Carer Reference
Group
Clinical Audit & Effectiveness Group
Service Line Governance &
Quality Groups (5)
Embedding Lessons Group
Regulation & Risk Working Group
Health & Safety Committee
Infection Control Committee
Medicines Management
Committee
Equality & Diversity Group
Appendix 8 – CQC Escalation Process
Identified Area of no
compliance with CQC
Standards
Via spot check audits /
whistle-blowing / incident
reporting / serious Incident /
complaint or internal
assessments / other route
Added to local risk registers
Issue escalated to Team
manager / Head of Service
and raised to GQC
Added to Directorate Risk
Register if deemed
appropriate
Added t Direcotrate risk
register if required
Action Plan developed by
Team and monitored by
Clinical Governance
Department / nominated staff
member / committee
Identified Actions
Implemented and
compliance with standards
assessed
Issue fully addressed –
escalation process stopped
and ongoing monitoring
continues
Continued non compliance
with standards
Escalated to Board and
added onto Trust Wide Risk
Register and monitored by
Board in line with Trust RM
processes
Revised Action Plan
developed / Overseen by
Executive Director
Identified Actions
Implemented and
compliance with standards
assessed
Issue fully addressed –
escalation process stopped
and ongoing monitoring
continues
Continued non compliance
with standards
Continued non compliance
with standards
Report to CQC and / SHA /
Commissioners if patient
safety compromised and /
or service suspended
OOrr
OOrr
Further actions
implemented and Issue
fully addressed or service
suspended / terminated
Appendix 9 - Quality Improvement Process
To deliver the continuous quality improvement required by the Trust‟s Quality Strategy and
framework the Trust has adopted the process outlined below. This process will be applied
across the Trust and also for each service line. This process will be in line with the strategic
direction of Trust and aim to address key areas of risk. It will be a live process that is
communicated widely and will result in the delivery of high quality services and assist with
the production of the Trust‟s annual Quality Account.
Qu
ali
ty I
nte
llig
en
ce
Process Outcome
Process 1
Aggregated Analysis of
core data (SI‟s, complaints,
incidents and performance)
data)
Outcome 1
Awareness of
areas requiring
improvement
Process 2
Agreement of changes
required and methodology to
be used, key milestones and
identified Trust lead
Outcome 2
Signed off Project
Initiation Plan
Process 3
Process of
involvement
commences in line
with project plan –
impact of changes
monitored
Outcome 3
Improved services/
procedures
Process 4
Utilisation and analysis
of data intelligence to
ensure services have
improved
Outcome 4
Assurance that
services have
improved
Appendix 10 - Quality Account Process
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Appendix 11 – Cost Improvement Plan (CIP) process
CIP ownership
Named individuals for each
scheme:
• Board sponsor
• Project Manager
• Lead Clinician
• Finance and HR leads
CIP structure
CIP Scheme Identified:
• Name of Scheme
• Financial Target
• Directorate/corporate area
• Project scope
• Link to Corporate Objectives
• Impact on Patient Pathway
• Commissioning
CIP PID
PID Assessment of:
Benefits – operational, clinical,
financial
Risks – clinical (QIA), financial &
regulatory risks and mitigations
Stakeholder Involvement – who are
they and what do they require
Milestones and monitoring – timing,
reporting process
Workforce – impact on staffing
levels
Communications – plan with
identified leads