The Mid Yorkshire Hospitals NHS Trust. Risk Management Strategy

Transcription

1 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 Type Strategy Status Draft Circulation Trust wide Pages 13 EIA neutral Date due for review September 2012 File path Page 1 of 23

2 Introduction and rationale 1. The Trust is committed to implementing the principles of governance, defined as the system by which the organisation is directed and controlled, at its most senior levels, to achieve its objectives and meet the necessary standards of accountability, probity and openness. The Trust recognises that the principles of governance must be supported by an effective risk management system that is designed to deliver improvements in patient safety and care as well as the safety of its staff, patients and visitors. 2. The Trust is required to have a Board approved policy for managing risk that identifies accountability arrangements, resources available and contains guidance on what may be regarded as acceptable risk within the organisation. 3. The Risk Management Strategy will also provide the structured approach to the management of risk as required by the NHS Litigation Authority risk management standards for acute trusts. Strategy 4. The Trust Risk Management Strategy will provide a systematic approach to the anticipation, prevention, mitigation and management of risk across all areas of the Trusts business. It is based upon the industry best practice. The strategy is reviewed and audited annually for compliance with legal requirements and with a view to defining areas for further enhancement. 5. The key objectives of this strategy are to provide the framework for achieving: Robust corporate governance The control and management of risk to achieve organisational objectives By implementing this strategy the Trust will also achieve: o o o o o Continued unconditional registration with the Care Quality Commission Compliance with the NHS Litigation Authority risk management standards for acute trusts Production of the assurance framework to enable the statement on internal control to be signed The integration of risk management within the Trusts strategic aims and objectives Integrated governance encompassing financial, clinical, corporate, information, performance and research governance systems. 6. The Trust encourages an open culture that encourages all staff and contractors to operate within the systems and structures outlined in this strategy. 7. The Trust will provide appropriate training in relation to risk management as outlined in the training statement. Scope 8. This strategy applies to all Trust employees, contractors and other third parties working within the Trust. Risk management is the responsibility of all staff; managers Page 2 of 23

3 at all levels are expected to take an active lead to ensure that risk management is a fundamental part of their operational area. Definitions 9. For the purposes of this strategy, the following definitions apply: Risk is defined as the uncertainty of outcomes whether positive opportunity or negative threat, of actions and events. The Risk Rating is the combination of the likelihood and impact of the event, and risk management is the process involved in identifying, assessing and judging risks, assigning ownership, taking actions to mitigate or anticipate them, and monitoring and reviewing progress. Duties and responsibilities The Trust Board 10. The Trust Board is accountable for ensuring a robust system of internal control is in place. The system of internal control ensures that: The Trust principle objectives are agreed Principle risks to those objectives are identified The effectiveness of these controls are independently assured Reports on unacceptable or serious risks and the effectiveness of control mechanisms are received Action plans are agreed and implemented to improve control over serious or unacceptable risks Policies are in place to determine what level of risk may be retained The system of internal control will be managed through the accountable officer and supported by an effective committee structure Chief executive 11. The Chief Executive, as accountable officer, is ultimately accountable before Parliament for all aspects of clinical and corporate governance including risk management. Operationally the Chief Executive has delegated responsibility for the implementation of risk management as defined below: Medical Director 12. The Medical Director has delegated authority for leading risk management within the Trust. Director of Finance 13. The Director of Finance has executive director responsibility for financial governance and all associated financial risks Director of Corporate Development 14. The Director of Corporate Development provides the lead on maintaining the Board assurance framework Executive directors 15. Executive directors are responsible for the management of strategic and operational risks within their own portfolios. Page 3 of 23

4 Associate Director Clinical Governance and Patient Safety 16. Responsibilities: Ensuring robust systems are in place for Serious Incident reporting and investigation; establish processes for tracking of progress Ensuring reporting systems are in place for directorates to report risks to Quality and Clinical Governance Committee Ensuring that risk management strategy fits with overall clinical governance strategy Manage the Clinical Risk Team Monitor the implementation of NPSA alerts and report on any risks arising from delayed implementation Assistant director governance and patient safety 17. Responsibilities Lead on the development of risk management strategies and policies Operational management of serious incident reporting to external bodies Lead for preparation for NHSLA Risk Management Standards accreditation Project Lead on implementation of an integrated risk management system across the Trust, including web based reporting Take the lead in organising with Trust Managers / staff the co-ordination, development and implementation of their risk register Manage the Trust wide level 3 risk register Assistant director emergency preparedness and continuity planning 18. Responsibilities Major incident preparedness Trust wide response to major public health issues (eg pandemic influenza) Business continuity to manage disruption to services from internal or external threat Risk Manager 19. The Trust Risk Manager will adopt the approach set out in the Health and Safety Executive guidance publication HS(G)65, "Successful Health and Safety Management. The Risk Manager will take a strategic role to achieve the objectives of the strategy, namely Advising on the development and content of health and safety plans and ensure that they meet the requirements of legislation. Take the lead in organising with Trust Managers / staff the co-ordination, development and implementation of their health and safety management systems. Measure and review progress to ensure the treatment/ improvement plans are being achieved and remain relevant. Undertake lead role of CAS Officer for the Trust. Health and Safety Manager Page 4 of 23

5 20. The Trust Health and Safety Manager will adopt the approach set out in the Health and Safety Executive guidance publication HS(G)65, "Successful Health and Safety Management. The Health and Safety Manager will take an operational role to achieve the objectives of the strategy, namely Communicating health and safety information to all staff at all levels. Carry out a programme of audit and review the findings and implement/ recommend changes to the health and safety management system. Review non clinical incident reports in order to ensure that appropriate action and investigations are undertaken and where necessary they form a risk register entry. Within the Trust, the officer designated as the Health and Safety Manager is identified through the Trust intranet as the competent person if they require further advice. Occupational Health Services 21. Responsibilities: Advise on the development and content of relevant health associated policies Take the lead in the provision of OH Care to employees of the Trust Measure and review those policies and activity related to the health of the employee, e.g. Accidental Inoculation, Manual Handling, Work related stress, VDU Carry out all relevant health surveillance in accordance with the current COSHH Regulations Support the writing of and implementation of staff related policies 22. In addition the role of the Occupational Health Service (OHS) is to provide relevant and timely support, education and assistance to ensure that managers and employees of the Trust: are better able: To understand the risk of any occupation to the health of the individual through relevant risk assessment training and pre employment job risk assessment processes. To provide support, instruction and guidance to staff where risks to health have been identified To undertake investigation of injuries/incidents where health has been placed at risk To support the manual handling link workers in providing them the time to undertake specific manual handling training in the workplace and that they remain up to date by attending regular education sessions. As per the Manual Handling policy. To access relevant risk assessment and manual handling training to ensure a greater level of involvement in the processes which affect staff health. To provide relevant and timely support for staff in relation to stress related issues in the workplace. Clinical Group Chairs and Directors 23. Responsibilities: Develop local risk management processes to reflect risk profile, including patient and staff incidents, incidents of violence and abuse, risk assessments from alert notices. Managing the level 2 risk register (risks rated 8 and above) ensuring that any risks rated as 15+ are brought to the attention of the Governance Interface Group, with confirmation of actions being taken to mitigate Page 5 of 23

6 Ensuring that all new staff undertake appropriate risk management mandatory training Ensuring that all levels of staff fully understand their responsibilities with regard to implementing all aspects of the Trust s risk management arrangements and that appropriate and effective risk management processes are in place within their designated area(s) and scope of responsibility; with all staff made aware of the risks within their work environment and of their personal responsibilities. Heads of Service 24. Responsibilities: Through group/directorate management boards and governance arrangements, develop local risk management processes that reflect their own individual risk profile. Ensure that risk assessments are undertaken with regular review through directorate and clinical governance forums, ensure these risks are reflected in the appropriate risk register with relevant treatment and action plans in place and managed. Manage the service risk register (level 1) of risks rated 1-6 Escalate any risks rated 8 and above Escalate significant unmanaged risks to relevant senior manager CSG Clinical Governance Managers 25. Responsibilities Ensure that risk scores have been validated prior to presenting risk register to CSG Governance Board Provide assurance to the CSG Chair regarding the accuracy of the risk rating and consistency of treatment plans across the CSG, reasonableness of the action plan co-ordinating analysis and learning from incidents, complaints and claims relevant to their areas. Ward / Department Managers 26. All managers must ensure that staff have the necessary information through mechanisms such as local induction, discussions at meetings and local awareness raising to enable them to work safely and to comply with the Trust s internal control systems. These responsibilities extend to anything affected by the Trust s business including patients, sub-contractors, members of the public, finances, facilities etc. 27. Managers must ensure that: They have adequate knowledge of and/or access to all legislation relevant to their area of responsibility and as advised by in-house experts, ensure that compliance with such legislation is maintained. Adequate resources are made available to provide safe systems of work, in line with risk assessment findings. This will include making provision for risk assessments, appropriate control measures and their implementation, raising outstanding concerns, ensuring safe working procedures / practices and continued monitoring and revision of the same. There is appropriate training available for all employees, e.g. Health and Safety, Fire, Moving and Handling, Food Hygiene, Resuscitation Training, use of medical equipment, Conflict Resolution, consent, management of patient identifiable information etc. and that appropriate staff attend as required by the Page 6 of 23

7 Training Needs Assessment and that relevant statutory and contractual professional registrations are kept up to date. Promoting greater risk management awareness amongst all staff through leading by example, and by ensuring that only properly trained and competent staff are responsible for assessing risks and determining adequate control measures within the working environment. Monitoring performance, health and safety standards including risk assessments and infection control measures, safe systems of work, use of personal protective equipment etc, ensuring that these are reviewed and updated regularly and the level of compliance with all agreed internal controls. Making adequate provision to ensure that fire and other emergencies are appropriately dealt with, in line with trust and local policies and arrangements for such incidents, including where investigations are carried out and subsequent meetings are carried out with enforcement bodies. Ensure that appropriate co-ordinated responses are provided to alert notices issued through the Central Alerting System, including nil returns, and responses to Field Safety Notices as issued by manufacturers. All Trust Employed Staff 28. It is the responsibility of all employees to: Report incidents/accidents, prevented incidents and unsafe occurrences using the trust incident reporting system. Assess and act on risk assessments in line with trust policies. Provide safe clinical practice in diagnosis, treatment and care. Be aware that they have a statutory duty to take reasonable care for their own safety and the safety of all others that may be affected by their actions or inaction. Comply with all trust policies, regulations and instructions to protect the health, safety and welfare of anyone affected by the trust s business. Be familiar with the Trust s Risk Management Strategy and Directorate/Department Clinical, and Health and Safety procedures, local arrangements for safe systems of work and other internal arrangements and controls, and comply with these. Neither intentionally, nor recklessly, interfere with, misuse or fail to use when required, any equipment provided for the protection of safety and health. Be aware of emergency procedures e.g. resuscitation, evacuation and fire precaution procedures etc. relating to their particular Directorate/Department locations. Participate in training programmes to ensure that they have undergone basic mandatory training specific to their role and function as required by the Trust. Independent Contractors 29. Independent Contractors are bound by statutory obligations in the same way as the trust (Health and Safety at Work Act 1974, Environment Act, COSHH Regulations, etc). As such Independent Contractors need to ensure that they are managing clinical and non-clinical risks appropriately. There should be a system of cooperation and co-ordination between the Trust and the Independent Contractor to ensure that this takes place. Committees which have responsibility for risk Page 7 of 23

8 30. Responsibility for specific risk management areas has been delegated to the following committees. A schematic of the Committee structure is given at Appendix A. Terms of reference for the Committees are given at appendix B. Quality and Clinical Governance Committee 31. The role of the Quality and Clinical Governance Committee (QCGC) is to oversee the risk management arrangements within the Trust and set the strategic direction for managing risk within the organisation. The Committee is responsible for preparing and monitoring the corporate risk prioritised action plan and providing an annual report to the Board on risk management arrangements. Governance Interface Group 32. The Governance Interface Group (GIG) is a subcommittee of QCGC and will deal with specific issues on behalf of QCGC that pertain to the corporate committee and the operational service. The GIG will not duplicate the business of QCGC 33. The focus of the committee will be on scrutiny and provision of assurance to QCGC. Risk Panel 34. The weekly risk panel is responsible for the coordination of immediate risks identified from incidents, complaints, litigation and media. Management Board 35. The Management Board is responsible for ensuring that risk management plans are operationalised. Audit Committee 36. The role of the Audit Committee is to provide assurance to the Board that effective internal control and governance processes are maintained and that the Trust s activities comply with law, guidance and codes of conduct governing the NHS. The components included in this assurance are counter fraud measures, risk management, information and communication, control procedures, monitoring, corrective action and assurance. Risk Forums 37. Clinical and non clinical service areas have existing governance groups that meet regularly. Time will be allocated within these groups to discuss risk management issues. The groups will be responsible for: Appropriate population of the risk register in line with the risk management strategy and risk register guidelines and validating all risk scores attributed For red risks automatically escalated from lower levels, reviewing the treatment plan and rescoring the current risk as appropriate Monitoring the implementation of treatment plans for locally managed risks Reviewing all risks on the risk register at least annually to verify they remain valid Page 8 of 23

9 Providing the corporate risk team with evidence that these responsibilities have been met Process for the management of risk 38. The Trust employs a number of mechanisms to systematically assess and manage its risks, all of which combined provide the Board with the required assurance that risks to the objectives are being appropriately managed. These processes can broadly be split into proactive and reactive risk management processes. Proactive risk processes: 39. Strategies, policies and procedures in addition to the risk management strategy, the Trust has a range of other policies in place to support the management of risk in the Trust. These are available on the Trust intranet site. Resilience management the Trust has in place a comprehensive Major Incident Plan together with a range of plans and other associated documents designed to ensure the resilience of the Trust in a range of situations that may limit the operating capacity of the Trust. These plans are tested on a regular basis and learning from these tests is fed back into relevant groups to ensure that processes are refined. Implementation of clinical guidance the trust has mechanisms in place to implement the latest guidance and recommendations from NSFs etc Standards and accreditation the Trust ensures that it meets a range of standards and accreditations Audit there is extensive audit activity within the Trust covering a range of issues. Findings from the reviews are fed back to appropriate service areas and reports made to the appropriate committee. Organisational learning the Trust seeks to learn from experience of external organisations; for example published reports from key regulators and investigations are reviewed and findings compared with current Trust policy and practice Training extensive training takes place across the Trust, much of which is regulated by professional bodies. As a minimum staff receive appropriate mandatory training as set out in the Mandatory Training Policy Risk registers/board assurance framework the trust is developing its risk assessment processes to ensure that they support the assurance framework. Further work is ongoing to develop the risk module of DATIX as a mechanism to manage risk registers consistently across the Trust. Clinical alert system this is the method of communication of essential information to Trust personnel in circumstances where the information is urgent, requires immediate action from of needs to be brought to the urgent attention of staff. Reactive risk process 40. The Trust also identifies potential risks from events that have already occurred. The main sources of information are: Page 9 of 23

10 Complaints The Trust has a robust complaint process that is responsible for handling all Trust complaints and ensures that all concerns are responded to within the agreed timescales. Serious complaints may be subject to a root cause analysis investigation. Information and action plans arising from complaints are used to develop or change service delivery. The Trust complaint process is described in detail in the Complaints Policy. Incidents the Trust has a system for reporting incidents and serious incidents which is described in the Patient Safety: accident and incident management procedure. All incidents are graded using a simple risk matrix consistent with that used for risk management. All incidents are investigated in accordance with their severity based upon risk Claims, litigation and inquests the Legal team work closely with the complaints and risk departments to ensure the early identification of potential legal claims against the Trust. The legal team liaises with the HM Coroner and clinicians in respect of the inquest process. Any concerns or recommendations raised by the Coroner are fed back to the appropriate clinical team and remedial action taken. The process for litigation is set out in the Claims Handling Policy. Post event analysis when something happens within the Trust that impacts on services, potential risks are identified and appropriate management action put in place to reduce or eliminate the possibility of a similar occurrence. This may be separate or complimentary to the processes described above. Assessment and recoding of risks 41. Risks identified in the processes described in this strategy will result in a risk assessment. Full guidance on completing risk assessments is contained in the Risk Register Guidelines. Risks identified through the risk assessment process will be recorded on the corporate system for risk registers. The Trust has established a tiered system of risk management, supported by its corporate system. The process for the management of risks will incorporate a combination of escalation and aggregation of risk at various levels within the organisation. Process for Board review of the Trust risk register 42. The Trust Board has an overarching responsibility for risk. The Quality and Clinical Governance Committee, the Audit Committee and the Governance Interface Committee all have specific responsibilities for risk. The Management Board has responsibility for operationalisation of actions to mitigate severe risks. 43. The Quality and Clinical Governance Committee will receive and review the Assurance Framework and significant risks on the risk register at least quarterly. The Audit Committee will monitor and review significant financial risks on the risk register at least annually. 44. The Trust Board Assurance framework and the Trust risk register will be presented to the Trust Board at least bi-annually. Implementation of this policy Training and support Page 10 of 23

11 45. The Trust has identified its risk management training needs and documented them within the Training Needs Analysis 46. Support will be provided through the Medical Directorate. Publication and distribution 47. All new starters will be made aware of the strategy through the induction process; managers are responsible for keeping staff up to date about changes within the strategy. 48. The Strategy will be posted on the Trust intranet; previous versions will be archived. Monitoring and assurance 49. The monitoring of compliance and assurance of the risk management strategy is set out below: An assurance framework which incorporates appropriate risks against objectives, controls, assurance, action plans and gaps in assurance will be presented to the Trust Board bi-annually and the Quality and Clinical Governance Committee quarterly The Trust risk register will be presented quarterly to the Quality and Clinical Governance Committee having been reviewed by the Management Board The Trust risk register will be presented to the Board bi-annually A report demonstrating the changes in risk profile of the Trust will be presented annually to the Board A quarterly NICE compliance report will be made to the Quality and Clinical Governance Committee A summary clinical governance report will be made quarterly to the Quality and Clinical Governance Committee A bi-annual report of achievement of risk management strategy objectives (appendix C ) will be presented to the Quality and Clinical Governance Committee The Medical Directorate will maintain a register of designated forums across the Trust which discuss and assess risk at operational and corporate level. Evidence that these forums are meeting and discharging their responsibilities will be collated by the assistant director in the form of minutes of meeting. Review of this policy 50. The Medical Director will commission an annual review of this strategy. Supporting and related document Risk register guidelines Patient safety: accident and incident management policy and procedure Claims Handling policy and procedure Complaints policy Page 11 of 23

12 Being Open policy Page 12 of 23

13 Appendix A Charitable Funds Committee Charitable Trustee s Board Management Board Trust Board MYHT Assurance Framework committees providing assurance to the Trust Board on control and or mitigation of principle risks Remuneration Committee MYHT Sub- Committee *^ Sub-groups/Committees Audit Committee Advisory, Reference groups i.e. Professional forums, PPI etc. Service Group Management Teams Individuals MYHT Sub- Committee MYHT Sub- Committee MYHT Sub- Committee Sub-groups/Committees Sub-groups/Committees Sub-groups/Committees Finance Resources Capital and HDP Committee Quality and Clinical Governance Committee External Groups * Operational - develops and implements policies and procedures, responsible for delivery of targets on behalf of CPB and monitors compliance ^ Provides assurance - on Key controls in place and mitigation of principle risks via annual programme, annual report and risk registers Page 13 of 23

14 Page 14 of 23

15 Appendix B QUALITY AND CLINICAL GOVERNANCE COMMITTEE Terms of Reference 1. Role of the committee The role of the Quality and Clinical Governance Committee is to provide assurance to the Trust Board on all matters relating to clinical quality and patient safety of the services provided by the Trust, including staff governance. 2. Membership Chair: Dr Margaret Faull Non Executive Director Mrs Anita Fatchett Non-Executive Director Mr Jack Kershaw Non-Executive Director Mr David Longstaff Non-Executive Director Professor Tim Hendra Medical Director (Joint lead director) Ms Tracey McErlain-Burns Chief Nurse/Director of Patient Experience (Joint lead director) Mrs Angela Watson Chief Operating Officer 3. Attendees The chief executive and chairman of the Trust are invited to attend the Quality and Clinical Governance Committee. The Foundation Trust project director attends the meeting in the capacity of company secretary. The chairman of the Audit Committee (where he/she is not a member) will attend at least one meeting per year. Two patient representatives identified from the LINKs and the Patient and Public Involvement database will attend the meeting for a term of three years. The associate director for clinical governance, associate medical director and the assistant director for patient experience will attend the meeting. Other directors and staff will attend at the invitation of the chairman, as required. 4. Quorum No business shall be transacted at the meeting unless at least one third of the members are present, including at least one non-executive Director and one executive director 5. Attendance It is expected that each member or named deputy attends all meetings and performance will be reported for each member in terms of attendance at the end of each financial year. A named deputy will not count towards the quorum. 6. Changes to the Terms of Reference The terms of reference will be reviewed annually; changes to the terms of reference of committees, including changes to the chairmanship or membership, are a matter reserved to the Trust Board. 7. Establishment of sub-committees Page 15 of 23

16 The Committee may establish sub-committees or groups made up wholly or partly of members of the Quality and Clinical Governance Committee to support its work. The terms of reference of such sub committees will be approved by the committee and reviewed at least annually. The committee may delegate work to the sub committee in accordance with the agreed terms of reference. Minutes of sub committees will be presented to the next meeting of the full committee. 8. Frequency of meetings The committee will meet a minimum of six times a year 9. Administration The chairman of the committee will agree the agenda for each meeting with the medical director and chief nurse. The agenda and papers will be distributed to member seven calendar days in advance of the meeting. The meeting will be administered by the Assistant Director for Governance and Patient Safety. All papers presented to the Committee should be prefaced by a summary of key issues and clear recommendations setting out what is required of the committee 10. Annual Plan The Committee will develop an annual programme of work for approval by the Trust Board at its first meeting of the financial year. The Annual Plan will be used to inform a review of the committee s effectiveness at the end of each year. 11. Reporting to Trust Board Minutes of the Quality and Clinical Governance Committee will be presented to the Trust Board at the next available meeting. These will be presented in draft form if the committee has not met to approve them. The Chairman of the Q&CG Committee will draw to the Trust Board s attention any issues of significance, including issues where the committee is unable to provide a satisfactory level of assurance. The committee will provide the Trust Board with an Annual Report setting out issues that have been considered by the committee, details of assurance provided, a review of the committee s effectiveness and evidence of compliance with the terms of reference. 12. Status of the meeting All committees of the Trust Board will meet in private. Matters discussed at the meeting should not be communicated outside the meeting without prior approval of the chair of the committee. Minutes of the meeting will be reported to the public session of the Trust Board unless they contain information which relates to an individual patient or member of staff or that is commercially sensitive. 13. Monitoring The annual report on assurance will provide a statement that enables the Trust Board to monitor the effectiveness of the QCGC. This will include levels of attendance, delivery against the forward looking work programme and the management of identified risk. Monitoring the performance of the Chair of the meeting, will be conducted in annual performance review by the Trust Chairman. 14. Terms of Reference 1. To provide assurance to the Trust Board on the clinical quality and safety of all services across the organisation Page 16 of 23

17 2. To provide assurance to the Board on objectives in the assurance framework which have been assigned to the committee and to approve actions to address gaps in assurance or gaps in control. 3. To review the trust risk register and alert the Trust Board to any risks scoring over 15 that cannot be adequately mitigated 4. To receive and review regular reports on matters relating to clinical quality and safety, linked to the five CQC regulated activities and including safeguarding and mortality reduction. 5. To work closely with and receive reports from the Governance Interface Group 6. To receive and review reports on complaints and incidents and lessons learned and monitor implementation of follow up action. 7. To receive and review reports relating to patient experience. 8. To review national reports relating to matters of clinical quality, patient safety and patient experience and approve local action plans and monitor implementation on behalf of the Trust Board. 9. To provide assurance to the Trust Board on the Trust s compliance with regulatory standards relating to clinical quality, patient safety, equality and diversity, human rights and information governance. 10. To receive reports on the outcomes of clinical audit activity and monitor follow up of recommendations. 11. To review action plans relating to matters of clinical quality and patient safety on behalf of the Trust Board 12. To receive and review reports on matters relating to staff governance 13. To ensure the Trust s culture is consistent with its values and promotes fairness and learning 14. To ensure that appropriate standards of professional regulation exist throughout the organisation 15. To approve those policies relating to clinical quality and safety that require Board approval and are not matters reserved to the Board. Document Control Author Ruth Unwin Contributors Members of the QCGC Date Version Final Review Annual review Circulation QCGC, Trust Board EIA Not formally assessed, or required to be assessed Status Public Pages 4 Page 17 of 23

18 THE MID YORKSHIRE HOSPITALS NHS TRUST TERMS OF REFERENCE FOR THE GOVERNANCE INTERFACE GROUP Purpose of the Committee The governance interface group (GIG) will be a subcommittee of the Quality and Clinical Governance Committee (QCGC) and will deal with specific issues on behalf of the QCGC that pertain to the corporate committee and the operational service. The GIG will not replicate or duplicate the business of the Management Board or the Quality and Clinical Governance Committee. The focus of the committee will be on scrutiny and provision of assurance to the QCGC and Management Board. The QCGC will be concerned with the operationalisation of governance issues and the Management Board with performance managing the operational agenda. The terms of reference (accountability) shall be: To discuss (process) clinical governance arrangements with clinical service groups and receive their reports using an agreed template To discuss (process) governance issues across the clinical service groups and with members of the QCGC, focussing on any risks that are raised and identifying the relevant action (aligned to patient safety) To agree (process) and prioritise those actions that arise (aligned to patient safety) To monitor (process) the action plans derived from discussion at the GIG and hold the clinical service groups to account for the implementation of key governance objectives (aligned to patient safety and clinical effectiveness) To monitor (process) progress within clinical service groups of corporate priorities (as identified through the QCGC) such as patient safety and the implementation of the leading improvement in patient safety programme initiatives (aligned to patient safety) To monitor (process) and discuss (process) standards of practice within clinical service groups as they relate to registration with the care quality commission noting that once the detail of registrable activities are known, it will be possible to identify which clinical service group has a leadership responsibility To review mortality alerts (process) arising on the Dr Foster system (or from other sources) within the service groups, agree appropriate actions and monitor the implementation of and sign off of the outcomes of agreed investigations (aligned to patient safety and clinical effectiveness) To monitor (process) the implementation of national guidance, CQC registrable activities, CQUINS and quality account initiatives with service groups being held accountable as follows: To discuss (process) the key issues that require operational intervention and monitor the delivery of those interventions in relation to medicines safety and infection control (the GIG does not replace the infection control committee and medicines management committee)(aligned to patient safety) To receive (process) reports from the patient safety and clinical effectiveness committee (structure) on the implementation of NICE and other national must dos such as managing the alerts from the National Patients Safety Agency, and to take Page 18 of 23

19 assurance that they are being operationalised (aligned to patient safety and clinical effectiveness) To ensure (process) that service groups have sufficient resources to complete their governance actions and to bring any risks to the attention of QCGC To report (process) the activities of the committee to QCGC through comprehensive minutes with key assurances clearly summarised at the end of each set of minutes To discuss (process) lessons arising from Coroner s inquests, claims, complaints and SI s (outcome) that reflect the need to change our internal processes. To oversee (process) the implementation of any patient recall that arises from an MDA alert To ensure (process) that decisions are arrived at following appropriate clinical engagement (possible Structure) through membership of the GIG To commission work through other groups which will report to the governance interface group (structure) To approve governance policies (process) The committee will have a forward looking annual work programme and a regular system of reporting on progress. The work programme will make explicit when the committee plans to take routine assurance from clinical service groups. At the end of each meeting, the chair will confirm the details of the work programme scheduled for review at the next meeting. Decisions taken by the committee will be operationalised through the clinical service groups, and reported to QCGC and CPB through submission of notes. Chairmanship and membership The meeting will be chaired by the medical director The terms of reference will also be reviewed annually at the end of the financial year and updated terms of reference submitted to QCGC for approval Members: Corporate members: Medical Director Chief Nurse Director of Infection Prevention and Control Director of Pharmacy Associated Director of Clinical Governance and Patient Safety Assistant Director Patient Experience Assistant Director of Governance and Patient Safety Service group clinical chairs Clinical Director of IM&T Each functional corporate member, eg Director of Infection Prevention and Control will have a named deputy who should attend if the corporate member is not available. Service Group Members: Associate Directors of Nursing Clinical Governance Manager Page 19 of 23

20 The Associate Director of Operations for each clinical service group will have a right to attend all meetings as will the chief executive. Other corporate directors may request the inclusion of agenda items and attend to discuss those issues. In order for the meeting to progress at least eight persons should be present excluding the Medical Director and/or Chief Nurse, and there must be at least one representative from each clinical service group present. This provides for 20 members. To be quorate the medical director or chief nurse must be present, there must be a representative of each service group and attendance must exceed 50%. The committee will be serviced by the Assistant Director Governance and Patient Safety. It is expected that each member attends all meetings and performance will be reported for each member in terms of attendance at the end of each financial year. No member should attend fewer than 60% of meetings annually. Meeting frequency The meetings will be held every 2 months alternating with QCGC. The notes of each meeting will be issued within 7 calendar days of the meeting taking place, such that they can be received by the following QCGC. Preparation for meetings The agenda for the meeting will be signed off by the Chair of the GIG. The agenda and papers will be issued no less than 7 calendar days before the meeting is scheduled to be held. Without exception, all papers will have a cover sheet explaining their purpose, who is sponsoring the recommendations, detail of risk associated with accepting the recommendations and the equality impact assessment. Papers scheduled as part of the work programme, without these details, WILL NOT BE ACCEPTED. Papers resulting from urgent matters arising which form part of the agenda in agreement with the Associate Director of Governance or the chair of the meeting will not be subject to such stringent expectation if time does not permit. In addition, all papers will comply with the Trust document control policy, and each will be formatted such that each paragraph is numbered and pages numbered at the bottom of the page if the document is greater than 2 sides of A4. Each meeting is expected to take no more than 3 hours. For convenience, the venues will rotate across all three main Trust sites. The notes of each meeting will be appended by an action log which will be reviewed as part of the agenda at the subsequent meeting. Monitoring The effectiveness of the GIG will be monitored and reviewed by QCGC annually with its terms of reference. Document Control Author Assistant director governance and patient safety Contributors Members of the GIG Date September 2011 Version 6 draft Review To be reviewed in September 2011 by the chair of the Governance Interface Group Circulation To members of the Governance Interface Group, copied to the QCGC EIA Not formally assessed, or required to be assessed Page 20 of 23

21 Appendix C Risk Management objectives 2011/13 The Trusts specific objectives for 2011/13 are to Ensure that patient safety and health and safety remain at the top of the Trust Board agenda. To embed regular executive safety walk rounds across all trust sites; the walk rounds are to be supported by non executive directors subject to availability. Continue to increase the level of awareness and understanding of risk management processes for all staff in order to develop effective performance and quality management systems and processes Ensure clinical safety by maintaining unconditional registration with the Care Quality Commission To support the implementation of the Quality Account priorities To support implementation of the Clinical Governance Strategy To undertake a review of policy documentation across acute and community services as it relates to compliance with NHS Litigation Authority risk management standards level one To deliver compliance with NHS Litigation Authority risk management standards level two To maintain level one compliance with CNST maternity standards To embed use of the Global Trigger Tool across all CSGs To embed the use of risk assessments and risk registers across all areas of the Trust To embed use of the electronic risk management system To implement web based risk and incident reporting To further develop an open and fair culture supported by the implementation of the Trusts Being Open policy Strengthen business continuity arrangements through the development of continuity plans and standard operating procedures Page 21 of 23

22 EQUALITY IMPACT ASSESSMENT FORM INITIAL ASSESSMENT/SCREENING An impact assessment is a way of finding out whether an existing or proposed policy affects different groups of people in different ways and whether there is adverse impact on a group. This form is to be used for new and existing policies and service developments, where a question is not applicable to your assessment, please indicate. Managers Name Linda White Directorate Assistant director -governance and patient safety Policy Title Risk Management Strategy Policy Statement The Trust is required to have a Board approved strategy for managing risk. It provides the overarching framework within which risk is manages within the organisation. Which groups does the policy benefit All Trust Staff Related polices that may be affected by changes The Risk Management Strategy is a document that underpins the majority of policies within the Trust. Names of staff and public (if applicable) who participated in the assessment, date of assessment Linda White Dr Rob Lane 6/9/11 Page 22 of 23

23 Indicate Y or N in each Box below in answer to following questions/statements AGE DISABILITY RACE RELIGION & BELIEF GENDER SEXUAL ORIENTATION Do different groups have different needs, experiences, issues and priorities in relation to the policy. Is there potential for, or evidence that the policy will promote equality of opportunity for all. Is there potential for, or evidence that, the policy will affect Different population groups differently (including possible discrimination against certain groups) Is there public concern in the policy area about actual, received or potential discrimination against a particular population or groups Is there doubt about answers to any of the above questions N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N If the answer to any of the above is yes an Intermediate assessment in the relevant area(s) is required. Intermediate Assessment Identify extra information/research to clarify whether there is an adverse risk: Page 23 of 23