LEEDS COMMUNITY HEALTHCARE NHS TRUST. Quality Committee Terms of Reference

Transcription

1 Appendix 1 LEEDS COMMUNITY HEALTHCARE NHS TRUST Quality Committee Terms of Reference Version: 3.3 Approved by: Leeds Community Healthcare NHS Trust Board Date Approved: 7 June 2013 Date issued: 7 June 2013 Review date: April 2014

2 Document History: Version: 3.2 Ratified by: Leeds Community Healthcare NHS Trust Board Date ratified: 7 June 2013 Name of author: Angie Clegg Executive (Nurse) Director of Quality Victoria Pickles Director of Corporate Affairs and Company Secretary Name of responsible committee/individual: Leeds Community Healthcare NHS Trust Board Date issued: 7 June 2013 Review date: April 2014 Related Committees/Groups Trust Board, Health, Safety and Experience Group Clinical Effectiveness Group Infection Prevention and Control Group Vulnerable, Adults and Mental Health Act Governance Committee Clinical Policy Group Safeguarding Committee Associated Documents Target audience: The Quality Strategy Incident reporting Strategy Risk Management Strategy Patient Experience, Dealing with, compliments, complaints and concerns Equality and Diversity Strategy Clinical Strategy Leadership Strategy Leeds Community Healthcare NHS Trust Board Quality Committee Contents Section Page 1. Introduction 3 2. Constitution 3 3. Membership 3 2

3 Section Page 4. Attendance 3 5. Meetings and quorum 4 6. Authority 4 7. Role and duties of the Committee 5 8. Monitoring effectiveness 6 9. Administrative arrangements Review Committee reporting structure 7 3

4 1. Introduction 1.1. Quality is considered by Leeds Community Healthcare NHS Trust as safe care which results in positive experience that is clinically effective. 1.2 In 2014 the Care Quality Commission introduced a new inspection regime that assesses the quality of care by testing services against 5 key questions: Are they safe? Are they effective? Are they caring? Are they responsive to people s needs Are they well-led? 1.2. The Trust has also identified a strategic objective related to quality Strategic Objective 1 to provide high quality, safe services, continuously improving patient experience and measuring our success in outcomes. 2. Constitution 2.1. The Committee is appointed by the Board and will be known as the Quality Committee (the Committee). The Committee has the executive powers delegated in the Scheme of Delegation and detailed in these Terms of Reference. 3. Membership 3.1. The membership of the Quality Committee will comprise: Three Non-Executive members (one of which will be the Chair and the other be the Deputy Chair. One of the Non Executives should have clinical experience. One of the members will be appointed Chair of the Committee by the Board). Chief Executive Executive Medical Director Executive (Nurse) Director of Quality 4. Attendance 4.1. In addition to the membership, the following participants are required to attend the meetings of the Committee: Head of Infection Prevention and Control Risk Manager Head of Experience Head of Effectiveness Clinical Effectiveness lead Patient Safety lead 4.2. Other Executive Directors and Senior Managers shall be invited to attend for discussions when the Committee is discussing areas of risk or operation that are their responsibility 5. Meetings and Quorum 4

5 5.1. The Chair will preside at all meetings. In extraordinary circumstances where the Chair cannot attend, the deputy chair shall preside A quorum shall be 50% of the membership of the Committee, including either the Chair or the Deputy Chair and at least one Executive. If the Committee is not quorate the meeting may be postponed at the discretion of the Chair. If the meeting does take place and is not quorate, no decision shall be made at that meeting and such matters must be deferred until the next quorate meeting. In the case of none agreement or no decision reached by the majority, the issue is to be escalated to the board for discussion The Committee will meet at least six times per year Special meetings of the Committee can be arranged for specific purposes as necessary The Committee will agree a meeting calendar on an annual basis, setting out the main work items to be carried out by the Committee at each meeting to ensure that adequate time is given to the main duties of the Committee Members are expected to attend all meetings If any member has an interest, pecuniary or otherwise, in any matter and is present at the meeting at which the matter is under discussion, he / she will declare that interest as early as possible and shall not participate in the discussions. The Chair will have the power to request that member to withdraw until the Committee s consideration has been completed The Chair of the Quality Committee may also act on urgent matters arising between meetings of the Committee, in line with the organisation s Chair s Action Prodedure. 6. Authority 6.1. The Committee s delegated decision making will be in accordance with the Trust s Scheme of Delegation as approved by the Board on an annual basis The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. 5

6 7. Role and Duties of the Quality Committee The Quality Committee will enable the Board to obtain assurance that high standards of care are provided by the Trust and, in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the organisation to: Promote safety and excellence in patient care; Identify, prioritise and manage risk arising from clinical care; ensure the effective and efficient use of resources through evidence-based clinical practice; and Protect the health and safety of trust employees The duties of the Quality Committee can be categorised as follows: 7.1. General governance Ensure that clinical governance is adhered to across the Trust and that there are effective monitoring arrangements in place to test this Oversee the continuing development of and enhancement of clinical strategies, systems and processes in relation to internal control, risk management and clinical safety Approve the Trust s Annual Quality Account before submission to the Board Approve the terms of reference and reporting arrangements of any sub-group and oversee the work of those groups Consider matters referred to the Committee by the Board and other Committees Receive and approve the annual Clinical Audit programme and review the outcome of clinical audits to ensure mechanisms are in place for action to be taken in response to recommendations Review and ratify policies and procedures relating to clinical quality in line with the Policy on Policies and Patient Group Directives Make recommendations to the Audit Committee on the annual programme of Internal Audit where it applies to matters within these terms of reference Ensure that appropriate governance arrangements are in place to support the consistent application of the Mental Health Act Safety Review clinical risk, ensure management and mitigation of clinical risks Receive serious incident reports and any incidents escalated by the Health, Safety and Experience Governance Group (HSEGG) Review all claims and ensure secure and effective management of them Receive and approve the annual Safeguarding Report and Infection Prevention and Control Report Review, monitor and develop the Trust systems and processes for compliments, complaints and incident management to ensure performance targets are achieved and organisational learning takes place. 6

7 7.3. Experience Ensure LCH develops a culture of excellence by involving patients, their carers, staff and key stakeholders and by seeking patient feedback on their experiences of health care Receive the outcomes from the Friends and Family Test from patients and staff and approve any associated action plans 7.4. Effectiveness Ensure that care is based on evidence-based practice and national guidelines Receive assurance on the effectiveness of the systems and processes for ensuring clinical safety Ensure systems to monitor the quality of services are in place and are functioning appropriately Monitor the systems and processes for ensuring compliance with the Care Quality Commission s and other inspectorate body standards Receive and review reports from external agencies for example, Care Quality Commission, National Patient Safety Agency; ensuring action plans are developed and performance managed to achieve recommended improvements Review mortality rates, identified trends and related action plans 8. Monitoring Effectiveness 8.1. The Board will receive the minutes of the Committee at the next appropriate meeting The Audit Committee will monitor the effectiveness of the Committee through receipt of an Annual Report, work plan and self assessment, in accordance with best practice. 9. Administrative Arrangements 9.1. The Committee will be supported by a nominated secretary who will: prepare the agenda and papers with the Chair and circulate; maintain accurate records of attendance, key discussion points and decisions taken and issue necessary action logs within five working days of the meeting; draft minutes for circulation to members within five working days of the meeting; maintain a database of any documents discussed and / or approved and recall them to the Committee when due; organise future meetings; and file and maintain records of the work of the Committee. 10. Review The purpose, function, responsibilities and duties of this Committee will be reviewed on an annual basis. 7