board assurance and escalation framework · 4. risk escalation process 5. board governance...

Board Assurance

And

Escalation Framework

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.


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.


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.


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


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


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


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


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


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


with standards


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

board assurance and escalation framework · 4. risk escalation process 5. board governance...

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