Quality and Safety Committee Terms of Reference
|
|
- Edmund Marsh
- 5 years ago
- Views:
Transcription
1 Approved May 2016 Quality and Safety Committee Terms of Reference 1. Constitution The Quality and Safety Committee is established as a sub-committee of The Hillingdon Hospitals NHS Foundation Trust (THH) Board of Directors. All members of staff are directed to co-operate with any request made by the Quality and Safety Committee. The Quality and Safety Committee will review these Terms of Reference on an annual basis as part of a self-assessment of its own effectiveness. Any recommended changes brought about as a result of the yearly review, including changes to the Terms of Reference, will require Board of Directors approval. 2. Authority The Quality and Safety Committee is directly accountable to the Board of Directors. The Committee only has delegated powers when specifically granted by the Board. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary. 3. Aim The Quality and Safety Committee provides the Trust Board of Directors with assurances around Quality and Safety within THH, that there are appropriate processes in place to identify gaps and manage them accordingly and that there are effective strategies in place to continually improve quality and safety.4. Objectives a. This Committee aims to aggregate the three themes that define quality: The SAFETY of treatment and care provided to patients safety is of paramount importance and cannot be compromised i.e. no patient harm and zero tolerance on avoidable harm. EFFECTIVENESS of the treatment and care provided to patients measured by both clinical outcomes and patient-related outcome The EXPERIENCE patients have of the treatment and care they receive how positive an experience people have on their journey through the organisation can be even more important to the individual than how clinically effective care has been.
2 b. All Committee Members will: Adhere to meeting protocols in Appendix A Have oversight of the Trusts Quality and Safety Improvement Strategy and Plan. Agree the annual quality accounts (which reflects the annual quality plan) and monitor progress; Approve the Trust's annual quality accounts before submission to the board; Monitor and scrutinise the Trust Quality and Performance Dashboard; Consider matters referred to the Quality and Safety Committee by its sub-groups. c. In relation to EFFECTIVENESS: To approve the annual clinical audit programme ensuring that it is approved by Board of Directors consistent with the audit needs of the Trust; To make recommendations to the audit committee concerning the annual programme of internal audit work, to the extent that it applies to matters within these terms of reference; Ensure the review of patient safety incidents (including near-misses, complaints, claims and Rule 43 coroner reports) from within the trust and wider NHS to identify similarities or trends and areas for focussed or organisation-wide learning; To monitor the impact on the Trust's quality of care of cost improvement programmes and any other significant reorganisations. To ensure the Trust is outward-looking and incorporates the recommendations from external bodies into practice with mechanisms to monitor their delivery d. In relation to SAFETY: To promote within the Trust a culture of open and honest reporting of any situation that may threaten the quality of patient care in accordance with the trust's policy on reporting issues of concern and monitoring the implementation of that policy; To encourage compliance with standards set by statutory and regulatory bodies Monitor the Trust s compliance with Care Quality Commission registration requirements, and ensure that action plans are developed and implemented to strengthen practice where required. Review NICE guidance compliance and ensure that action plans are in place to address non-compliance and where this cannot be achieved that relevant risk assessment is undertaken. To encourage that where practice is of high quality, that practice is recognised and propagated across the Trust: To promote a patient safety improvement culture e. In relation to EXPERIENCE: To have overview responsibility for the 5 key areas as described by the Care Quality Commission: Safe, Effective, Caring, Responsive & Well led. To monitor the Trust's compliance with the national standards of quality and safety of the Care Quality Commission, and Monitor' licence conditions that are relevant to the Quality and Safety Committee's area of responsibility, in order to provide relevant assurance to the Board so that the Board may approve the Trust's annual declaration of compliance and corporate governance statement;
3 To oversee the Trust's work progress on Patient Experience to support organisational learning. To monitor the extent to which The Trust meets the requirements of commissioners and external regulators. To ensure diversity issues are considered to support the treatment and care received by all patients. 5. Method of Working The Quality and Safety Committee will have a standard agenda. At every meeting, the following item headings will be including on the agenda: o Welcome and apologies for absence o Declarations of Interest o Minutes of the previous meeting and action log o Divisional Review o Review of one Key Strategic Aim o Scrutiny of one Domain o Performance Exception reporting o External Quality, Safety and Intelligence Monitoring o Regulation and Compliance Status o Any other business as per annual calendar o Date of next meeting Other items may be included on the agenda from time to time as directed by the Chair of the Committee. All Minutes of the Quality and Safety Committee will be presented in a standard format. All meetings will receive an action log (detailing progress against actions agreed at the previous meeting) for the purposes of review and follow-up. 6 Membership and Quorum The Committee shall be appointed by the Board from the Non-Executive and Executive Directors of the Trust. It shall consist of not less than six members and shall include: o At least four Non-Executive Directors one of whom will be appointed Chair o The Chief Executive Officer o The Medical Director o The Executive Director of the Patient Experience and Nursing o The Chief Operating Officer A quorum shall be three members, two of whom must be a Non-Executive Director together with either the Medical Director, the Executive Director of the Patient Experience and Nursing or the Chief Operating Officer. Given the Committee s status as a Committee of the Board, it is expected that members should make every effort to attend Committee meetings and will attend every meeting unless there are good reasons preventing attendance The Board will appoint one of the Non-Executive Directors as Chair of the Committee. Other Executive Directors and senior managers may also be invited to attend to cover specific agenda items. The Deputy Director of Nursing and Integrated Governance and the Clinical Director of Quality and Safety shall attend, and other
4 attendees may be invited as necessary, to assist in feeding information up and down the organisation. This includes reporting back through the organisation following QSC meetings. For the avoidance of doubt, Trust employees who serve as members of the Quality and Risk Committee do not do so to represent or advocate for their respective department, division or service area but to act in the interests of the Trust as a whole and as part of the Trust-wide governance structure. If a meeting is not quorate it may still proceed, however any decisions must be subsequently agreed by those not present. 7. Frequency and Support of Meetings Meetings shall be held bi-monthly, with at least 6 meetings per year Additional meetings may be held on an exceptional basis at the request of any three members of the Quality Committee. Urgent items may be handled by . Members are expected to attend a minimum of 75% of Committee meetings throughout the year. The Trust Secretary shall ensure that the Committee is appropriately supported which will include: a. Agreement of agenda with Chair and attendees and collation of papers b. Organising the attendance of appropriate persons to meetings (other than those who would usually attend) c. Taking the minutes and keeping a record of matters arising and issues/ actions to be carried forward d. The agenda, papers and minutes of the Quality and Safety are considered to be confidential. e. Advising the Committee on pertinent matters. 8 Reporting Lines The Quality and Safety Committee will report to the Board of Directors after each meeting. The minutes of all meetings of the Quality and Safety Committee shall be formally recorded and a summary of key issues submitted to the next Board. Matters of material significance in respect of quality and safety will be escalated to the following meeting of the Board of Directors. However, any items that require urgent attention will be escalated to the Chief Executive and Chairman at the earliest opportunity and formally recorded in the Quality and Safety Committee minutes. The Quality and Safety Committee will ensure that an appropriate governance structure is in place to deliver effective clinical quality that reports to the Committee and this will be reviewed annually. The following groups shall report to the Quality and Safety Committee: a. Patient Safety Committee b. Regulation and Compliance Committee c. Experience and Engagement Group The above groups will report as per the Quality and Safety Committee Work plan, and also at times when requested by the Quality & Safety Committee. The reports provided by the groups should be in written format unless agreed by the chair.
5 Reviewed by: Q&S Committee Date: May 2016 Review date: May 2017
6 Appendix A Quality and Safety Committee: Meeting Principles OVERALL OBJECTIVE To create the maximum value from our meetings, we will need to be disciplined so that we can focus on the right set of issues, at the right level for the right amount of time. To enable this we need a good set of principles Principles for the Q&S Meetings For the meetings to be effective and efficient, the following principles will be used: The meeting will start and finish on time. The number of additional items for the next agenda over and above items from the annual planner will be discussed and agreed at the end of each meeting where possible. Any other requests for items to be included on the agenda to be submitted to Ritu Sharma at least one month before the meeting. The agenda and all the relevant papers must be circulated to the members attending the meeting at least 5 working days before the meeting. No late items will be allowed unless agreed by the Chair of the meeting. For each item on the agenda, there must be absolute clarity on the purpose for the item. There will be 3 categories: 1. INFORM where the purpose is to inform the members of the meeting. Only questions for clarification will be allowed for such items. 2. CONSULT Where the purpose is to consult the Q&S Meeting. This should only be done where it is a real consult and group input will help the owner of the item to develop their thinking and planning on the subject. The paper should clearly flag the areas on which views will be sought during the meeting. The person presenting the paper will assume the paper has been read and use the time available to get maximum feedback on the paper. 3. DISCUSS and AGREE The paper should clearly flag what decisions are sought from the Q&S meeting. Time on the agenda should be structured to allow a full discussion and the decision to be reached. The item owner should discuss with key people off-line, where it is felt this would be helpful. There are 6 Q&S meetings during the whole year and given the importance of Quality and Safety it is the expectation that Directors will attend all of the meetings unless you have agreed your absence with the CEO for the Execs and the Chair for the NEDs. No deputies will be allowed unless there are exceptional reasons given the important nature of some of the items on the agenda. The owner of any next step must take personal responsibility that they agree with both the action and the time frame they are signing up to, as it will be expected that they meet these fully.
7 Build in quality reviews at the end of the meeting and for any big items on the agenda that haven t gone well, so that we can continue to learn how we can improve the value created from these meetings. To help our development we should give feedback to each other on how we have behaved and acted during the meeting. This is an absolute must, if we are to grow as individuals and team. We must challenge unacceptable behaviours or attitude. Blackberry or phones should NOT be used during the meeting so that you are focused on the meeting. We will need to collectively own all of the above to ensure that it happens and feel free to challenge where appropriate. November 2015
QUALITY COMMITTEE. Terms of Reference
QUALITY COMMITTEE Terms of Reference CONSTITUTION 1. The Board of Directors approved the establishment of the Quality Committee (known as the Committee in these terms of reference) for the purpose of:
More informationSample CHO Primary Care Division Quality and Safety Committee. Terms of Reference
DRAFT TITLE: Sample CHO Primary Care Division Quality and Safety Committee Terms of Reference AUTHOR: [insert details] APPROVED BY: [insert details] REFERENCE NO: [insert details] REVISION NO: [insert
More informationCLINICAL GOVERNANCE AND QUALITY COMMITTEE Terms of Reference
CLINICAL GOVERNANCE AND QUALITY COMMITTEE Terms of Reference CONSTITUTION 1. The Board of Directors approved the establishment of the Clinical Governance and Quality Committee (known as the Committee in
More informationCLINICAL GOVERNANCE AND QUALITY COMMITTEE. Final - Terms of Reference - Final
CLINICAL GOVERNANCE AND QUALITY COMMITTEE Final - Terms of Reference - Final CONSTITUTION 1. The Board of Directors approved the establishment of the Clinical Governance and Quality Committee (known as
More informationPatient Safety, Quality & Risk Committee Terms of Reference
Patient Safety, Quality & Risk Committee Terms of Reference Status: Chair: Clerk: Frequency of meetings: Quorum: Sub Committee of the Trust Board Non Executive director Associate Director of Governance
More informationQuality and Governance Committee. Terms of Reference
Quality and Governance Committee Terms of Reference 1. Constitution 1.1 The Clinical Commissioning Group s Governing Body hereby resolves to establish a Committee of the Governing Body known as the Quality
More informationTerms of Reference Quality Governance Assurance Committee 26 March 2018
Terms of Reference Quality Governance Assurance Committee 26 March 2018 Safe & Effective Kind & Caring Exceeding Expectation Agenda Item No: 11.3 Meeting Date: 26 th March 2018 Trust Board Report Title:
More informationClinical Advisory Forum DRAFT Terms of Reference
Clinical Advisory Forum DRAFT Terms of Reference 1. Constitution 1.1. The Trust Executive Committee (TEC) hereby resolves to establish a Forum to be known as the Clinical Advisory Forum (the Forum). The
More informationQuality Committee Terms of Reference
Quality Committee Terms of Reference 1. Authority 1.1. The Quality Committee (the Committee) is constituted as a standing committee of the Trust Board. The Committee is a Non-Executive Committee and has
More informationPatient & Carer Reference Group
Patient & Carer Reference Group Samantha Wood Patient Experience & Partnerships Manager Approved by XXX on (date) 1. Purpose of Committee References to the Reference Group shall mean the Patient & Carer
More informationPrimary Care Quality Assurance Framework (Medical Services)
PCC/15/021 Primary Care Quality Assurance Framework (Medical Services) 1.0 Introduction: From the 1 April 2015 the responsibility for monitoring quality and responding to concerns arising from General
More informationWarrington CCG Operational Safeguarding Children Health Forum. Terms of Reference
Warrington CCG Operational Safeguarding Children Health Forum 1 Introduction Terms of Reference 1.1 The Operational Safeguarding Children Health Forum (the Health Forum) is established within the Safety
More informationSpecialised Commissioning Oversight Group. Terms of Reference
Specialised Commissioning Oversight Group Terms of Reference Specialised commissioning oversight group terms of reference 1 1.1 Purpose NHS England is responsible for commissioning specialised services
More informationAppendix 1 MORTALITY GOVERNANCE POLICY
Appendix 1 MORTALITY GOVERNANCE POLICY 1 Policy Title: Executive Summary: Mortality Governance Policy For many people death under the care of the NHS is an inevitable outcome and they experience excellent
More informationQuality and Safety Committees
Quality and Safety Committees Guidance and Resources This document replaces the previously published Quality and Safety Committee(s) Guidance and Sample Terms of Reference Document (May 2013). It forms
More informationCLINICAL AND CARE GOVERNANCE STRATEGY
CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016
More informationNHS North West London
NHS North West London Shaping a Healthier Future Pre-Consultation Business Case Volume 6 Appendices A1 & A2 Edition: 1 20 June 2012 Page 1 of 29 APPENDIX A1 Programme Governance A.1.1 Key governance principles
More informationEnsuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS
Ensuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS April 2017 Contents Page 1. Purpose 2 2. Key Functions 2 3. Governance and Administrative
More informationNHS East and North Hertfordshire Clinical Commissioning Group. Quality Committee. Terms of Reference Version 4.0
NHS East and North Hertfordshire Clinical Commissioning Group Quality Committee Terms of Reference Version 4.0 1. Introduction 1.1 The Quality Committee (the committee) is established in accordance with
More informationMortality Policy. Learning from Deaths
Mortality Policy Learning from Deaths Name of Author and Job Title: Frank Jacobs, Datix project manager Ian Brandon, Head of governance and risk Name of Review/ Development Body: Ratification Body: Mortality
More informationQUALITY COMMITTEE. Terms of Reference
QUALITY COMMITTEE Terms of Reference This Committee will report to NHS Halton CCG Governing Body on the development, improvement and monitoring of all areas of quality. This will include clinical effectiveness,
More informationLearning from Deaths Policy
Learning from Deaths Policy The Learning from Deaths Policy sets out the minimum acceptable standards of the national learning from deaths programme. Policy group General Document Detail Version 1 Approved
More informationReview of Terms of Reference of Quality Assurance Committee
Review of Terms of Reference of Quality Assurance Committee Governing Body meeting 3 May 2018 H Author(s) Sponsor Director Purpose of Paper Sue Laing, Corporate Services Risk and Governance Manager Mandy
More informationGovernance and Quality Committee Review. Wendy Pugh Director of Operations and Nursing. Innovation Tom Jinks - Governance Manager.
Board meeting date: 29 th May 2013 Agenda Item number:10.1 Enclosure:5 Title and Quality Committee Review Accountable Director: Author (name & title): Wendy Pugh Director of Operations and Nursing Rosie
More informationPutting Barnsley People First. Quality and Patient Safety Committee Terms of Reference
Putting Barnsley People First Quality and Patient Safety Committee Terms of Reference 1. Introduction NHS Barnsley Clinical Commissioning Group Quality and Patient Safety Committee 1.1 The Clinical Commissioning
More information12. Safeguarding Enquiries: Responding to a Concern
12. Safeguarding Enquiries: Responding to a Concern 1 12.1 Statutory Safeguarding Enquiries Section 42 Councils are required by law to carry out safeguarding enquiries for those individuals who meet the
More informationDate 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager
TB 099/15 Meeting title Report title Trust Board Risk Management Strategy Date 4 th September 2015 Lead director Report author FOI status Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate
More informationBirmingham CrossCity Clinical Commissioning Group Deprivation of Liberty Safeguards (DoLS) Policy: Supervisory body Functions
Birmingham CrossCity Clinical Commissioning Group Deprivation of Liberty Safeguards (DoLS) Policy: Supervisory body Functions Policy Number Purpose of document To ensure that that the rights of patients
More informationA meeting of NHS Bromley CCG Governing Body 25 May 2017
South East London Sector A meeting of NHS Bromley CCG Governing Body 25 May 2017 ENCLOSURE 4 SOUTH EAST LONDON 111 AND GP OUT OF HOURS MEMORANDUM OF UNDERSTANDING SUMMARY: The NHS England Commissioning
More informationLearning from Deaths Policy
Learning from Deaths Policy Version: 3 Approved by: Board of Directors Date Approved: October 2017 Lead Manager: Associate Medical Director for Patient Safety and Clinical Risk Responsible Director: Medical
More informationLearning from Deaths Policy. This policy applies Trust wide
Learning from Deaths Policy This policy applies Trust wide Document control page Name of policy Learning from Deaths Policy Names of linked Learning from Deaths Procedure procedures Accountable Medical
More informationCOMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:
MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE. 1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards
More informationInternal Audit. Healthcare Governance. October 2015
October 2015 Report Assessment G A G G G This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted or
More informationNHS 111 Clinical Governance Information Pack
NHS 111 Clinical Governance Information Pack This pack is designed to help you develop your local NHS 111 clinical governance framework and explain how it fits in to the wider context. It takes you through
More informationRevised Terms of Reference Trust Management Committee
Revised Terms of Reference Trust Management Committee Safe & Effective Kind & Caring Exceeding Expectation Agenda Item No: 11.5 Meeting Date: 26 March 2018 Title: Revised Terms of Reference for Trust Management
More informationNHS England (Wessex) Clinical Senate and Strategic Networks. Accountability and Governance Arrangements
NHS England (Wessex) Clinical Senate and Strategic Networks Accountability and Governance Arrangements Version 6.0 Document Location: This document is only valid on the day it was printed. Location/Path
More informationInternal Audit. Health and Safety Governance. November Report Assessment
November 2015 Report Assessment G G G A G This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted
More informationQuality Strategy (Refreshed March 2015)
Quality Strategy 2012-2017 (Refreshed March 2015) 1 Table of Contents 1. Executive Summary... 3 2. Drivers for improvement... 4 2.1 The Trust s ambition - vision and mission... 4 2.2 Corporate Strategy...
More informationBurton Hospitals NHS Foundation Trust. On: 30 January Review Date: November Corporate / Directorate. Department Responsible for Review:
POLICY DOCUMENT Burton Hospitals NHS Foundation Trust MANAGEMENT OF EXTERNAL AGENCY VISITS, INSPECTIONS, ACCREDITATION AND RESULTING RECOMMENDATIONS Approved by: Trust Executive Committee On: 30 January
More informationALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS
ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE Date of Issue:- Version
More informationPolicies, Procedures, Guidelines and Protocols
Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure
More informationChildren and Families Service Quality Assurance Framework
Children and Families Service Quality Assurance Framework 2016-2018 [IL0: UNCLASSIFIED] Document Control Version Date Summary of Changes Changes Made by Draft / V001 28 July 2016 First draft of the Quality
More informationTrust Board Meeting: Wednesday 13 May 2015 TB
Trust Board Meeting: Wednesday 13 May 2015 Title Update on Quality Governance Framework Status History For information, discussion and decision This paper has been presented to Quality Committee in April
More informationMINUTES. Name of meeting. Quality and Clinical Governance Committee. Date and time Tuesday 2 May :30-17:00. Venue. Board Room, Dominion House
MINUTES Name of meeting Quality and Clinical Governance Committee Date and time Tuesday 2 May 2017 14:30-17:00 Venue Board Room, Dominion House Name Title Chair Dr Sue Tresman (ST) Lay Vice Chair (Lay
More informationNHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 14. Date of Meeting: 29 th June 2018 TITLE OF REPORT:
NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 14 Date of Meeting: 29 th June 2018 TITLE OF REPORT: AUTHOR: PRESENTED BY: PURPOSE OF PAPER: (Linking to Strategic Objectives)
More informationThe Mid Yorkshire Hospitals NHS Trust. Risk Management Strategy
The Mid Yorkshire Hospitals NHS Trust Risk Management Strategy Document control Author Assistant director governance and patient safety Director sponsor Medical Director Date August 2011 Version 6 Draft
More informationWELSH RENAL CLINICAL NETWORK TERMS OF REFERENCE
INTRODUCTION WELSH RENAL CLINICAL NETWORK TERMS OF REFERENCE In accordance with WHSSC Standing Order 3, the Joint Committee may and, where directed by the LHBs jointly or the Welsh Government must, appoint
More informationDocument Details Title
Document Details Title Quality and Equalities Impact Assessment (QEIA) Process Guidance Trust Ref No 2046-45852 Local Ref (optional) Main points the document This document explains the process for QEIA,
More informationPlease indicate: For Decision For Information For Discussion X Executive Summary Summary
Governing Body 22 March 2017 Details Part 1 X Part 2 Agenda Item No. 10 Title of Paper: Board Member: Author: Presenter: PAHT Quality Improvement Plan Catherine Jackson, Executive Nurse Catherine Jackson,
More informationLearning from Deaths Policy LISTEN LEARN ACT TO IMPROVE
Learning from Deaths Policy LISTEN LEARN ACT TO IMPROVE EQUALITY IMPACT The Trust strives to ensure equality and opportunity for all, both as a major employer and as a provider of health care. This policy
More informationSafeguarding Committee. Held on Tuesday, 10 th January pm at Hawthorn House, Ransom wood Business Park, Mansfield
Working on behalf of NHS Newark and Sherwood CCG, NHS Mansfield and Ashfield CCG, NHS Rushcliffe CCG, Nottingham North and East CCG, NHS Nottingham West CCG, NHS Bassetlaw CCG Safeguarding Committee Held
More informationClinical Audit Strategy 2015/ /18
Audit Strategy 2015/16 2017/18 Audit Strategy v8 Head of Integrated Governance Oct 2014 1 CLINICAL AUDIT STRATEGY, 2015/16 to 2017/18 Executive East Cheshire NHS Trust sees clinical audit as a cornerstone
More informationPatient Experience Strategy
Patient Experience Strategy 2013 2018 V1.0 May 2013 Graham Nice Chief Nurse Putting excellent community care at the heart of the NHS Page 1 of 26 CONTENTS INTRODUCTION 3 PURPOSE, BACKGROUND AND NATIONAL
More informationNHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 10. Date of Meeting: 31 st August 2018 TITLE OF REPORT:
NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 10 Date of Meeting: 31 st August 2018 TITLE OF REPORT: AUTHOR: PRESENTED BY: PURPOSE OF PAPER: (Linking to Strategic Objectives)
More informationSalford Integrated Care System Governance Framework: Adult Health and Care Services FINAL
Salford Integrated Care System Governance Framework: Adult Health and Care Services FINAL 1 Background and Scope Salford is a forward thinking health and social care economy and as such has established
More informationMATERNITY SERVICES RISK MANAGEMENT STRATEGY
Trust Board Agenda Item 8.3 Enc 10 Appendix 1 January 2012 MATERNITY SERVICES NORTH CUMBRIA MATERNITY SERVICES RISK MANAGEMENT STRATEGY 2011-13 DOCUMENT CONTROL Author/Contact Head Of Midwifery / Clinical
More informationClinical Audit Policy
Clinical Audit Policy DOCUMENT CONTROL Version: 5 Ratified by: Quality Assurance Group Date ratified: 3 July 2017 Name of originator/author: Clinical Quality Lead Senior Clinical Audit Facilitator Name
More informationCentral Alerting System (CAS) Policy
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray
More informationCOMMISSIONING FOR QUALITY FRAMEWORK
This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version COMMISSIONING FOR QUALITY FRAMEWORK Document Title: Commissioning for Quality Framework
More informationGuide to the Continuing NHS Healthcare Assessment Process
Guide to the Continuing NHS Healthcare Assessment Process Continuing NHS Healthcare (CHC) is a package of care arranged and funded solely by the NHS, where it has been assessed that the person s primary
More informationTHE ADULT SOCIAL CARE COMPLAINTS POLICY
THE ADULT SOCIAL CARE COMPLAINTS POLICY April 2009 Reviewed: January 2018 1 Cambridgeshire County Council Contents 1.0 Purpose Page 3 2.0 Principles Page 3 3.0 Accessing information about how to raise
More informationJOB DESCRIPTION. The post holder will focus on urgent care but may take responsibility for specialist projects and other services when required.
JOB DESCRIPTION Job Title: Deputy Medical Director Reports to: Medical Director, Urgent Care Location: Across Greenbrook urgent care services. Key Working Relationships: Director of Operations; Director
More informationFORTH VALLEY CLINICAL AND CARE GOVERNANCE FRAMEWORK
HEALTH AND SOCIAL CARE INTEGRATION: FORTH VALLEY CLINICAL AND CARE GOVERNANCE FRAMEWORK The Scottish Government, National Health and Wellbeing Outcomes: A framework for improving the planning and delivery
More informationDirect Commissioning Assurance Framework. England
Direct Commissioning Assurance Framework England NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources
More informationCREATIVE SOLUTIONS FORUM. Terms of Reference
CREATIVE SOLUTIONS FORUM Terms of Reference Version 3 June 2016 OVERVIEW Services and commissioners are seeing an increase in the numbers of people presenting with highly complex pictures of substance
More informationSafeguarding & Wellbeing Policy
Safeguarding & Wellbeing Policy 4.0 June 17 June 19 (unless an earlier review is required by legislative changes) All Midland Staff, Contractors and Volunteers Rebekah Newton, Director of Retirement Living
More informationWorkforce and Organisational Development Committee. Minutes of the meeting held on in the Board Room, Ysbyty Gwynedd and via videoconference
Workforce and Organisational Development Committee Minutes of the meeting held on 13.3.14 in the Board Room, Ysbyty Gwynedd and via videoconference Present: Dr P Higson Ms J Dean Dr C Tillson Mr K McDonogh
More informationQuality Assurance Committee Annual Report April 2017 March 2018
Quality Assurance Committee Annual Report April 2017 March 2018 Quality Assurance Committee Annual Report April 2017 March 2018 1. Introduction The role of the quality assurance committee is to provide
More informationTitle of report Freedom to Speak Up Guardian (FSUG) Trust Board in public
Title of report Freedom to Speak Up Guardian (FSUG) Trust Board in public Date: Thursday 26 th July 2018 Agenda item: 6.2 Executive sponsor Report author(s) Report discussed previously: (name of subcommittee/group
More informationWOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE
Wolverhampton Clinical Commissioning Group WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE Minutes of the Quality and Safety Committee Meeting held on Tuesday 12 th May 2015 Commencing
More informationQuality, Safety & Experience (QSE) Committee. Minutes of the Meeting Held on Wednesday 29 th March 2017 in the Boardroom, Carlton Court, St Asaph
1 Minutes QSE Public 29.3.17 V1.0 Present: Quality, Safety & Experience (QSE) Committee Minutes of the Meeting Held on Wednesday 29 th March 2017 in the Boardroom, Carlton Court, St Asaph Mrs Margaret
More informationComplaints, Compliments and Concerns (CCC) Policy
Complaints, Compliments and Concerns (CCC) Policy Central and North West London NHS Foundation Trust (CNWL) is committed to providing quality NHS services and adopting best practice in listening and responding
More informationPolicy on Learning from Deaths
Policy on Learning from Deaths Version number: 1 Consultation: Governance Committee Board Committee Director of Quality Assistant Director of Governance & Compliance Patient Safety Manager Ratified by:
More informationNational Waiting Times Centre Board. Clinical Governance Committee
Board Strategy National Waiting Times Centre Board Name Q-Pulse No Summary Associated documents Target audience Board-Strategy-3 Outlines the Board s approach to delivery of safe and effective care through
More informationVersion Number: 004 Controlled Document Sponsor: Controlled Document Lead:
Chief Investigators and Principal Investigators in Research Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Policy Governance To set out the responsibilities of
More information2. DEVELOPING AND DELIVERING A SINGLE GOVERNANCE STRUCTURE
GOVERNANCE COMMITTEE SEPTEMBER 2018 SINGLE GOVERNANCE COMMITTEE PROPOSAL 1. INTRODUCTION As both Trusts continue to work more closely together and work is in progress to achieve a formal merger it is necessary
More informationNHS CHOICES COMPLAINTS POLICY
NHS CHOICES COMPLAINTS POLICY 1 TABLE OF CONTENTS: INTRODUCTION... 5 DEFINITIONS... 5 Complaint... 5 Concerns and enquiries (Incidents)... 5 Unreasonable or Persistent Complainant... 5 APPLICATIONS...
More informationQuality Strategy
Quality Strategy 2017-2020 Contents 05 Foreword 06 Introduction 06 Equality & Diversity 07 Context for this Strategy 08 Definition of Quality 10 Quality Objectives 10 Strategic Quality Objectives 16 Quality
More informationPOLICY ON THE IMPLEMENTATION OF NICE GUID ANCE
POLICY ON THE IMPLEMENTATION OF NICE GUID ANCE Document Type Corporate Policy Unique Identifier CO-019 Document Purpose To outline the process for the implementation and compliance with NICE guidance and
More informationAgreement between: Care Quality Commission and NHS Commissioning Board
Agreement between: Care Quality Commission and NHS Commissioning Board January 2013 1 Joint Statement This agreement sets out the strategic intent and commitment for the Care Quality Commission (CQC) and
More informationPATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE
PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE Page 1 DOCUMENT CONTROL SHEET Name of Document: Patient Safety and Quality Committee Terms of Reference Version: 5 File Location / Document Name:
More informationUnique Identifier: Review Date: November Issue Status: Approved Version No: 1.4 Issue Date: November 2017
Policy Authors Name & Title: Dr Mark Jackson, Director of Research & Informatics Dr Raphael Perry, Medical Director Scope: Trust Wide Classification: Non Clinical Replaces: version 1.3 To be read in conjunction
More informationNorthumbria Healthcare NHS Foundation Trust. Charitable Funds. Staff Lottery Scheme Procedure
Northumbria Healthcare NHS Foundation Trust Charitable Funds Staff Lottery Scheme Procedure Version 1 Name of Policy Author Alison Nell Date Issued 1 st March 2017 Review Date 1 st March 2018 Target Audience
More informationIndependent Group Advising (NHS Digital) on the Release of Data (IGARD)
Document filename: Independent Group Advising (NHS Digital) on the Release of Data (IGARD) Directorate / Programme IGSA Project IGARD Document Reference Status Final Owner Martin Severs Version 1.6 Author
More informationCODE OF CONDUCT CODE OF ACCOUNTABILITY IN THE NHS
CODE OF CONDUCT CODE OF ACCOUNTABILITY IN THE NHS CODE OF CONDUCT Public Service Values General Principles Openness and Public Responsibilities Public Service Values in Management Public Business and Private
More informationCollaborative Agreement for CCGs and NHS England
RCCG/GB/15/164 Collaborative Agreement for CCGs and NHS England East Midlands Collaborative Commissioning Oversight Group (EMCCOG) 1. Particulars 1.1. This Agreement records the particulars of the agreement
More informationNHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 12. Date of Meeting: 23 rd March 2018 TITLE OF REPORT:
NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 12 Date of Meeting: 23 rd March 2018 TITLE OF REPORT: AUTHOR: PRESENTED BY: PURPOSE OF PAPER: (Linking to Strategic Objectives)
More informationTERMS OF REFERENCE. Transformation and Sustainability Committee. One per month (Second Thursday) GP Board Member (Quality) Director of Commissioning
TERMS OF REFERENCE Committee: Frequency Of Meetings: Committee Chair: Membership: Attendance: Lead Officer: Secretary: Transformation and Sustainability Committee One per month (Second Thursday) GP Board
More informationJOB DESCRIPTION Paediatric Rapid Assessment Staff Nurse - Urgent Care Centre
JOB DESCRIPTION Paediatric Rapid Assessment Staff Nurse - Urgent Care Centre Job Title: Paediatric Rapid Assessment Staff Nurse Reports to: Location: Key Working Relationships: Lead Nurse (Clinically)
More informationMEMORANDUM OF UNDERSTANDING
MEMORANDUM OF UNDERSTANDING Memorandum of Understanding Co-Commissioning Between NHS England Lancashire And South Cumbria And Clinical Commissioning Groups 1 Memorandum of Understanding (MoU) for Primary
More informationWelcome, Apologies for Absence and Declaration of Board Members Interest
DRAFT Minutes of the of the Royal Cornwall Hospitals NHS Trust held on Thursday 30 March 2017 11.00 13.00 in the Knowledge Spa, Royal Cornwall Hospital Present: Mr Jim McKenna Ms Kathy Byrne Ms Catrin
More informationSafeguarding Adults Policy March 2015
Safeguarding Adults Policy 2015-16 March 2015 Document Control: Description Comment Title Document Number 1 Author Lindsay Ratapana Date Created March 2015 Date Last Amended Version 1 Approved By Quality
More informationCCG Policy for Working with the Pharmaceutical Industry
CCG Policy for Working with the Pharmaceutical Industry 1. Introduction Medicines are the most frequently and widely used NHS treatment and account for over 12% of NHS expenditure. The Pharmaceutical Industry
More informationHealthwatch Cambridgeshire and Peterborough Escalation Policy
Healthwatch Cambridgeshire and Peterborough Escalation Policy Purpose of this document This policy sets out Healthwatch Cambridgeshire and Peterborough s role in: 1) Collating people s views and experiences
More informationMORTALITY REVIEW POLICY
MORTALITY REVIEW POLICY Version 1.3 Version Date July 2017 Policy Owner Medical Director Author Associate Director of Patient Safety & Quality First approval or date last reviewed July 2017 Staff/Groups
More informationLearning from Deaths Framework Policy
Learning from Deaths Framework Policy Profile Version: 1.0 Author: Dr Nigel Kennea, Associate Medical Director (Mortality) Executive/Divisional sponsor: Medical Director Applies to: All staff Date issued:
More informationNHS SHETLAND CLINICAL GOVERNANCE STRATEGY
NHS SHETLAND CLINICAL GOVERNANCE STRATEGY 2010-13 Clinical governance is the defining heart and inspiration of quality in the NHS Aidan Halligan 2006 Last version date: March 2007 Next Formal Review January
More informationJOB DESCRIPTION Emergency Nurse Practitioner (ENP) / Advanced Nurse Practitioner (ANP) / Emergency Care Practitioner (ECP) Urgent Care Centre (UCC)
JOB DESCRIPTION Emergency Nurse Practitioner (ENP) / Advanced Nurse Practitioner (ANP) / Emergency Care Practitioner (ECP) Urgent Care Centre (UCC) Job Title: Reports to: Salary/ Grade: Location: Key Working
More informationWhat is this Guide for?
Continuing NHS Healthcare (CHC) is a package of services that is arranged and funded solely by the NHS, for those people who have been assessed as having a primary health need. The issue is one of need.
More informationPRIVACY MANAGEMENT FRAMEWORK
PRIVACY MANAGEMENT FRAMEWORK Section Contact Office of the AVC Operations, International and University Registrar Risk Management Last Review July 2014 Next Review July 2017 Approval SLT14/7/176 Effective
More information