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NLG(19)103

DATE OF MEETING 7 May 2019

REPORT FOR Trust Board of Directors – Public

REPORT FROM Dr Kate Wood, Medical Director

CONTACT OFFICER Angie Legge, Associate Director for Quality Governa nce

SUBJECT Progress against the KPMG actions on Divisional Gov ernance

BACKGROUND DOCUMENT (IF ANY) None

PURPOSE OF THE REPORT: To note the progress against actions and revised ti mescales for delivery

EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)

This report presents an update on the 12 action rec ommendations made by KPMG on Governance Key developments have been:

• Divisional Clinical Directors established as triumv irate leads within divisions

• Consultation on Clinical Leaders and Matron post • Establishment of the Quality & Safety Committee, un derpinned

by the Quality Governance Group • Establishment of the SI Panel with divisional clini cal attendance

Key areas of work going forward are:

• Review of the routes for information on topic progr ess to ensure assurance feeds in at the appropriate level with escalation of key positives and concerns to Quality and Safety Committee

• Revision of the Serious Incident process to improve investigation and report quality

• Review of the structure and roles within Governance • Working with divisions to improve complaints manage ment • Improvements in divisional engagement on actions fo llowing

clinical audit • Review and support of divisional governance process es

TRUST BOARD ACTION REQUIRED

The Board is asked to note the progress and revised timescales

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Purpose The purpose of this report is to provide an update on the response to the recommendations made in the KPMG report. Background KPMG, an independent internal auditing company, were commissioned by the Trust to review governance, specifically, on behalf of the Medical Directorate to:

• Review the Trust Quality Governance structures and information flows to provide assurance of effectiveness and identify key issues

• To consider the effectiveness of the resource allocation and suitability for the needs of the organisation

• To identify the future quality governance needs of the Trust

The final report was completed by August 2018, with the observations being made in June 2018. The report looked at Trust-wide governance arrangements, divisional governance arrangements, reviewed the Emergency Department and Maternity Services against the CQC actions, and made 12 recommendations, all medium or low priority. Assessment This report presents an update on the 12 action recommendations made by KPMG on Governance.

- 3 recommendations have been completed, but work continues to embed and increase the effectiveness of the process

- 2 recommendations are still within the initial timescale - 1 recommendation is being reported through a different route (the CQC action plan) - 3 recommendation updates include proposed new target dates for the ongoing work - The remaining 3 actions are in progress.

Key developments have been:

- Divisional Clinical Directors established as triumvirate leads within divisions - Consultation on Clinical Leaders and Matron post - Establishment of the Quality & Safety Committee, underpinned by the Quality

Governance Group - Establishment of the SI Panel with divisional clinical attendance

Key areas of work going forward are:

- Review of the routes for information on topic progress to ensure assurance feeds in at the appropriate level with escalation of key positives and concerns to ensure Quality and Safety Committee are aware of all key risks to Quality and Safety as these emerge

- Revision of the Serious Incident process to improve investigation and report quality - Review of the structure and roles within Governance to enable support towards

corporate and divisional improvements - Working with divisions to improve the complaints management - Improvements in divisional engagement on actions following clinical audit - Review and support of divisional governance processes.

Recommendation The Board is asked to note the progress made, and the change in timescales for delivery, highlighted in yellow within the action plan.

Recommendations and Progress to date

Key:

Action more than 6 months delayed Action in progress, but not yet completed Completed, but awaiting confirmation that it is embedded Change embedded

KPMG Recommendations

Action to be taken Responsible Lead

Start Date

Progress to date Expected Completion Date

Review of Divisional Clinical Director roles

To ascertain and agree period of time required for these posts to be established

Medical Director Chief Operating Officer

Aug-18 Divisional Clinical Directors established as the lead within triumvirates, generally consisting of a Head of Nursing and Divisional general manager are in place across 4 Divisions. Clinical Support Services is the exception with a different senior leadership structure made up of 5 key roles. These roles are developing.

Oct-18

Recruitment of Clinical Leads within each of the Divisions

Develop Job Descriptions ensuring these posts increase clinical leadership and governance and are outcome driven. Review of the effectiveness of the positions to be scheduled as part of appraisal process

Divisional Clinical Directors / Chief Operating Officer/Medical Director

Aug-18 The recruitment process is not yet started within the divisions. Consultation and advertisement of Clinical Leads posts will need to be publicised widely across the Trust as they are appointed. The consultation exercise regarding clinical leads has been undertaken and led by S Stacey and A Shankar. A paper has been produced with timescales which will be shared with those who participated in the consultation prior to commencing recruitment.

Jan-19

The Quality and Safety Committee and Divisional Assurance

Process agreed for quarterly presentation of report to committee. The Committee Terms of Reference are shared with the Divisions and they are informed of the expected level of scrutiny for submitted papers. To ensure a Template is provided for divisional reporting. To undertake a six month review of the Terms of Reference and the effectiveness of the committee. Agenda setting and planning meetings between the Medical Director and Chair to take place prior to each meeting.

Non-Executive Director / Medical Director

Aug-18 Meetings are currently scheduled, but divisional assurance reports are not yet providing the scope of assurance needed. The purpose and terms of reference of the meetings for divisions was revised and is being shared with divisions. A new Draft template was taken to QGG with a view to discussion before Q&SC. This was rejected by divisions, so further work is taking place to look at amending the divisional governance report to enable this to then provide assurance to QGG and Q&SC. In line with the recommendations a review of the effectiveness of the Quality & Safety Committee will need to take place. Agenda setting is taking place as recommended. This aspect is green.

Apr-19

Quality Governance Group

Meeting to be chaired by the Medical Director

Medical Director Aug-18 The meeting is recently in place and being chaired by the Medical Director. The meeting is being held monthly with attendance from each of the divisions. Terms of Reference (TORs) have been developed for the group. The number of agenda items remains a challenge and further work has been carried out offering guidance to divisions when presenting. The function and assurance coming through the group will be reviewed as part of work on the assurance routes, by the Associate Director for Quality Governance. This will inform the annual review and review of Terms of Reference.

Mar-19

Serious Incident (SI) Panel

The Trust should establish a SI Panel. Divisional Clinical Directors should be responsible for the sign off of all SI in their division

Medical Director / Deputy Medical Director

Aug-18 The Serious Incident Panel is in place, Terms of Reference (TORs) have been developed and have been recently reviewed. The meeting is establishing itself and the process of declaring SIs is better informed by the specialist knowledge of the members of the group. The panel process will be reviewed as part of a review of the SI process, looking at the information brought to panel, membership and wider terms of reference. Serious Incidents go to divisions for sign off, but that process is not as robust as it needs to be. This will be easier when the new template is in place. In summary, while the action has been done, further work is in progress to embed and improve the process effectiveness.

Dec-18

Operational Matron Role

Trust to undertake development sessions with the Matron group, discussing roles and responsibilities and performance outcomes. The revised arrangements should be reviewed after being in place for approximately four months

Chief Nurse Aug-18 The consultation process has concluded, and Matron roles will change in April 2019. Support, development and review of these roles will take longer, with a view to completion in August 2019.

Apr-19

Risk and Governance

Co-location of the risk and governance facilitators within the divisions and aligned to the divisional priorities. Consideration of the banding of the Head of Risk role. Consideration of an additional clinical Governance Lead within the Medicines and Surgery Divisions

Associate Director of Quality Governance / Medical Director

Aug-18 The Job Descriptions within the Risk and Governance dept. require updating. Banding of roles has been considered, with a view to introducing some limited band 6 posts to increase line management effectiveness. The current banding for the Head of Risk is considered appropriate. The role of the Risk and Governance Facilitators requires review, in terms of their objectives and the requirements within divisions. Plans have been made to review divisional requirements. The aim is to have the facilitators located partly both in division and in Governance, but this needs to be mapped with the role requirements. Additional Governance Leads within Medicine and Surgery divisions is under consideration.

Aug-19

Complaints Management

Complaint Action Plans to be developed by the Divisions to ensure appropriate accountability and ownership. Divisional Clinical Directors to take responsibility for approving and sign off of complaints letters within their division

Head of Complaints and Patient Experience

Aug-18 Letters are being signed off by the Divisional Clinical Directors and a cover letter signed by the Chief Executive is included with all complaints responses. Given the work needed to support divisional ownership of the complaints process a stepped approach has been necessary. This has included moving to a co-located model for the facilitators to support better working relationships with the triumvirate and ultimately begin to remove delays in respects of access and understanding. This was a necessary first step prior to commencing any additional progress across the divisions. Ensuring action planning is meaningful and therefore lessons are learnt is vital to the development of a person centred process and therefore to give this the attention necessary it has formed part of the larger piece of work around the complaints process, therefore impacting on the timescales. The Complaints Manager has taken oversight of the upheld/not upheld decision outcomes from all signed off complaints from February 2019 and will commence work alongside the Patient Experience Facilitators within the divisions to support their development of meaningful action plans. This is an intensive piece of work and the amended timescale supports this, a work plan to support this is being devised – proposed deadline June 2019 The new revised internal timescale will be closely monitored during this next quarter

Nov-18

Clinical Audit Divisions to work with the Clinical Audit Facilitators to increase local ownership of the Audit program and learning from the actions

Head of Quality and Assurance

Aug-18 The team is working to ensure divisional ownership of audits is increased, learning identified and actions taken. Consideration will be given to adding the outstanding actions to the Performance slides if there is no improvement by the end of May 2019 A Clinical Audit Strategy is being developed which will cover a three year period.

Mar-19

Divisional Governance Meetings

Divisions to ensure that staff are aware of meeting dates well in advance of the dates. Divisions to explore whether a common SPA/PA could be arranged allowing core time for medical staff to attend governance meetings. Trust to develop a template meeting agenda and Governance Report for Divisional Governance Meetings to ensure all key areas are covered. An alternative meeting should be established for the ratification of policies to allow the meetings to focus on specific clinical governance matters and function more effectively. An action log should be enclosed for each governance meeting

Divisional Clinical Directors / Divisional General Managers / Head of Nursing

Aug-18 Divisional Governance Meetings are taking place within the divisions, but are not always quorate. Further work is required to ensure they take place regularly and are not cancelled, (particularly due to operational pressures) as this impacts on agenda length when they do take place. The new Associate Director for Quality Governance will attend a sample of divisional governance meetings from each division, and look to the development of templates to support improved governance. The first two of these has taken place in April 2019; feedback was provided to Surgical Division and will be provided to Women division (Obstetrics & Gynaecology).

Aug-19

Review of Clinical Areas

Recommendations to be incorporated in to the Trust CQC Action Plan

Divisional Clinical Directors

Aug-18 This work is reported separately as part of the CQC action plan.

Apr-19