QUALITY COMMITTEE. Terms of Reference

Transcription

1 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, patient safety and patient experience. The Committee will provide assurance on the systems and processes by which the CCG leads, directs and controls its functions in relation to quality of care in order to achieve organisational objectives. The Committee is established in accordance with NHS Halton Clinical Commissioning Group s (the CCG) Constitution, Standing Orders and Scheme of Reservation & Delegation. These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of the Committee. The Committee will act to review and assure the Governing Body in relation to quality, demonstrating early recognition of service issues and ensuring appropriate action is taken. 1. Membership Chief Nurse (Chair) Registered Nurse (Vice Chair) Chair of the Governing Body 2 Lay Member Healthcare Professional Representatives from the Governing Body (including GP, Nurse and Secondary Care Doctor) Local Authority Representation in relation to care quality and safeguarding (Adults and Children) Contract Clinical Leads Governing Body Practice Manager Representative HealthWatch representation Deputy Chief Nurse Public Health Consultant Representative In attendance Engagement Manager Senior Commissioning Manager Representative Safeguarding Lead - Vulnerable Adults and Children team Deputy Medical Director for NHS England (Merseyside) Chair Halton Peoples Health Forum Other relevant officers will be invited to attend in line with agenda items

2 2. Quorum The Chair or Vice Chair of the Committee must be present and six members at least one of which must be a General Practitioner representative. 3. Remit and responsibilities 3.1 Clinical Effectiveness The Committee is responsible for overseeing quality processes across all commissioned services. It will assure the Governing Body that all activity relating to quality is coordinated and transparent ensuring a coherent and systematic review of the system including early warning of service failures. The Committee will:. Receive and review at every meeting the Early Warning System for all providers. Investigate any activity within its Terms of Reference and produce a work programme. Be responsible for ensuring compliance with clinical quality and safety governance arrangements when undertaking its Terms of Reference Establish and approve the Terms of Reference of such reporting Working Groups as it believes are necessary to fulfil its Terms of Reference and receive reports from such groups. In the first instance the key working groups shall be the Primary Care Development Group (in relation to Primary Care Quality) and the Medicines Management Group Produce regular reports using the Early Warning Quality and Safety Framework/Dashboard for the Governing Body Receive assurance regarding the management of Contract Quality key performance indicators relating to commissioned services through receipt of written updates from Contract quality groups (Quality Boards or Clinical Quality and Performance Groups). Ensure that unwarranted variations in clinical practice are identified and addressed through the use of benchmarking and clinical evidence. Identify areas of improvement in care delivery through the Quadrangulation of data including programme budgeting, morality rates and outcomes. Ensure that Quality Schedules, Quality Risk Profiles and Commissioning for Quality and Innovation Schemes deliver continuous quality improvements. Review any information, notification or advice received from the NHS England, Quality Surveillance Group, National Quality Board, CQC, Monitor or any External Regulator which relates to or has a bearing on an NHS care provider s provision including the results of national clinical audit information and confidential enquiries. Review joint Clinical Investigation Reports which may be commissioned from time to time.

3 Receive and review progress reports relating to a Remedial Clinical Action Plan and any Remedial Clinical Action Plan report. To review and advise appropriate in relation to new or reviewed national guidelines 3.2 Patient Safety Co-ordinate, prioritise, agree and monitor actions to minimise risks across Halton CCG commissioned services Receive and report on any Serious Untoward Incidents and or reports or investigations of Significant Events Analysis/audits Receive summary report and ensure actions are delivered upon Patient Safety Incidents or reports or investigations of Patient Safety Incidents Receive and review reports into death rates through HSMR and SCMI reporting for all appropriate providers and advise action as appropriate. Receive and review any CQC (Keogh) Report for local providers ensuring actions are in place to manage any issues identified. Receive overviews and outcomes of any independent investigation or reviews carried out on any local providers and ensure findings and action are in place to manage any issues identified Review lessons learnt from any unexpected deaths investigated by the coroner and share learning across Providers. Ensure there are appropriate arrangements in place in respect of Safeguarding as recommended by the Quality Committee. Review all safeguarding incidents and ensure providers have robust safeguarding arrangements in place included approval of policies Receive and act upon outcomes of reviews of Safeguarding Incidents - trends, themes and lessons learnt To receive reports to evidence that complaints are properly investigated lessons learnt and feedback given, and that all appropriate details are analysed alongside patient safety indicators by the Committee To receive regular (quarterly) reports and assurance in relation to safeguarding activity in Halton and the performance of providers in relation to safeguarding KPIs. Review and recommend systems to review all claims and secure management of them Receive, review and advise appropriate actions in relation to medicines related incidents and medicines safety

4 Receive, review and advise as appropriate, incidents in relation to health equipment 3.3 Patient Experience & Engagement Ensure lessons are learnt from patient experience intelligence and serious untoward incidents Receive and act upon findings of Patient Experience reports undertaken locally, regionally or nationally To receive regular reports in relation to Friends and Families Test implementation and early adopters. To approve and ensure there are appropriate policies and procedures in place for the handling of patient complaints, concerns or enquiries in accordance with relevant regulations. To review and approve CCG engagement plans both CCG specific and in partnership with others including the Local Authority. To receive and review reports from outcome of engagement and stakeholder events and provide assurance to the Governing Body in relation to patient and other stakeholder engagement 3.4 NHS Constitution To receive for the CCG and all providers assurance in relation to compliance with NHS constitution 4. Frequency of meetings The Committee shall meet monthly. 5. Reporting This Committee will submit a Key Issues report to the Governing Body Meeting. This Committee will also prepare reports at the request of the Governing Body. 6. Responsibility of Committee Members and Attendees Members of the Committee have a responsibility to: Attend meetings, having read all papers beforehand. Act as champions, disseminating information and good practice as appropriate. Identify agenda items to the Secretary at least fifteen working days before the meeting. Submit papers at least eleven working days before the meeting.

5 Make open and honest declarations of their interests at the commencement of each meeting notifying the Committee Chair of any agreed management arrangements, or to notify the Committee Chair of any actual, potential or perceived conflict in advance of the meeting. Uphold the Nolan Principles and all other relevant NHS Code of Conduct requirements. 7. Administrative Arrangements The Committee will be supported by an appropriate Secretary that will be responsible for supporting the Chair in the management of the Committee s business. The Secretary will ensure: Correct minutes are taken and once agreed by the Chair, distributing minutes to the members within five working days of the meeting taking place. A Key Issues report is produced following the meeting and submitted to the next meeting of the Governing Body. An Action Log is produced following each meeting and any outstanding actions are carried forward until complete. The agenda and accompanying papers are distributed to members at least five working days in advance of the meeting date. They provide appropriate support to the Chair and Committee members. The papers of the Committee are filed in accordance with NHS Halton CCG policies and procedures. The Work Plan will be agreed at the start of each financial year and will be approved by the Governing Body. The focus of the work programme will be in ensuring the delivery of Quality in services both health and social care. 8. Date and Review These Terms of Reference were approved at the Governing Body meeting on 2 nd October Version: [3] Review date: [September 2015]