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 2015 (QC2015.38) and to Trust Management Executive in April 2015 (TME2015.112) Board Lead(s) Tony Berendt, Medical Director Key purpose Strategy Assurance Policy Performance Update on Quality Governance Framework Page 1 of 14
Executive Summary 1. The primary objective, both for the Trust and Monitor, of the Quality Governance Framework is to ensure that patients receive safe, high quality care in keeping with the Trust s values and strategic objectives. 2. Improvements in the framework should be viewed in part through the lens of building a just culture where the organisation and its staff continuously identify, assess and seek to mitigate risks, and learn lessons when quality defects (at their most extreme, causing patient harm) occur. 3. Since the Monitor assessment in September 2014, the immediate learnings from that process, and the detailed feedback subsequently received by the Trust, work has been in progress to improve several elements of the Quality Governance Framework (QGF). 4. At the time of the September assessment, the Trust, with endorsement from a limited assurance review by the Trust internal auditors, KPMG, had self-assessed the QGF score at 2.5. Monitor assessed the Trust at 4.5. The upper limit for authorisation is 3.5. 5. This paper sets out much work that has been done to strengthen the Quality Governance Framework since September 2014. Of note, however, is that despite this work, several Never Events have occurred in different settings in the Trust, demonstrating the emergent nature of risk and the need to see the QGF as but one element of a continuous process of quality monitoring and improvement. 6. The paper has previously been received and discussed at Quality Committee (QC2015.38), where the principle of rescoring the Quality Governance Framework scores was agreed, and at Trust Management Executive (TME) (TME2015.112) where new scores were agreed based on the progress deemed to have been made. 7. Recommendation The Trust Board is asked to note the progress made in Quality Governance and to consider whether the evidence presented justifies the favourable movement in the QGF scores from those previously determined by Monitor to those proposed by TME. Update on Quality Governance Framework Page 2 of 14
Update on Quality Governance Framework 1. Purpose 1.1. The purpose of this paper is to provide the Trust Board with an update on the work completed, and in progress, to address issues in the Quality Governance Framework, as identified by Monitor in its assessment undertaken in September 2014. In addition, the paper sets out the modified Quality Governance Framework scores that the Trust Management Executive proposes are agreed in response to this body of work. 2. Background 2.1. The Quality Governance Framework (QGF) sets out a series of questions that the Trust must answer, evidencing each response and self-assessing with a score. The total score is the sum of scores for each of the ten questions posed; a perfect score would be zero, and the worst possible score 40, (which would represent major omissions in quality governance in each of the ten domains). 2.2. Monitor has set a threshold for authorisation of applicant Foundation Trusts of 3.5 or less. 2.3. Prior to the assessment, the Trust self-assessed with a score of 2.5. Following assessment, Monitor scored the Trust at 4.5. Improvement, to Monitor s satisfaction, is essential for authorisation. 2.4. Monitor provided the Trust with detailed feedback and while a formal action plan was not considered appropriate by either the Trust or Monitor, key actions to be undertaken were agreed. The remainder of this paper considers progress with those actions. 2.5. It is however essential to hold in mind that the primary objective, both for the Trust and Monitor, of the Quality Governance Framework is to ensure that patients receive safe, high quality care in keeping with the Trust s values and strategic objectives. Improvements in the framework should be viewed in part through the lens of building a just culture where the organisation and its staff continuously identify, assess and seek to mitigate risks, and learn lessons when quality defects (at their most extreme, causing patient harm) occur. 2.6. Since the Monitor assessment process, the Trust has experienced an unprecedented number (6 in 2014/15) of Never Events, which are Serious Incidents Requiring Investigation that are widely considered to represent failures of basic safety processes, and hence to be entirely avoidable. Progress against the action plan for improving quality governance since September 2014 must be viewed with these events in mind, which demonstrate the emergent nature of risk and the QGF should be viewed as but one element of a continuous process of quality monitoring and improvement. 3. Areas for improvements in Quality Governance / Progress 3.1. This section provides a complete assessment of all elements of the QGF. It also outlines the progress against the commitments made by the Trust in writing to Monitor, following the formal feedback received from Monitor. Update on Quality Governance Framework Page 3 of 14
3.2. Does quality drive the trust s strategy? (1A). 3.2.1. A refreshed Quality Strategy has been agreed by the Trust Board (January 2015, [TB2015.09]) following discussion and approval at the Trust Management Executive and the Quality Committee in their December 2014 meetings [TME2014.314 & QC2014.85]. 3.2.2. Following the January 2015 Trust Board meeting, workshops involving approximately 100 staff and patient representatives were held later that month to contribute to the Quality Priorities and the Quality Strategy Implementation Plan. The draft Implementation Plan was reviewed at Quality Committee in February 2015 [QC2015.05]. 3.2.3. The priorities as set out in the Quality Account [QC2015.23] flow from the refreshed Quality Strategy and are referenced in the Implementation Plan. 3.3. Is the Board sufficiently aware of potential risks to quality? (1B). 3.3.1. In its December meeting, the Quality Committee received a paper [QC2014.87] detailing an enhanced mechanism for use with CIP schemes from January 2015. The enhanced mechanism is designed to test and monitor the potential impact of CIPs interacting and aggregating to affect risk levels. 3.3.2. This arrangement will increase the understanding and collective challenge on schemes which cross Divisions or have a Trust-wide impact. Divisions will be able to identify schemes from one Division which impact adversely on another. 3.3.3. A report format demonstrating aggregation of identified risks has been presented to the April 2015 Quality Committee [QC2015.28] and has subsequently been reviewed at the April 2015 meeting of the CIP Executive Group. 3.3.4. Divisional quality metrics for key Trust-wide measures have been presented to the Quality Committee and Trust Board in the Quality Report since January 2015 [TB2015.05, QC2015.04, TB2015.28 and QC2015.24]. 3.3.5. The Trust has recently revised, and further developed, its existing guidance in relation to the identification and description of risks used in risk registers [QC2014.87]. The revised guidance is being incorporated into CIP scheme processes to enable risks to be more effectively considered by staff developing CIP schemes. 3.3.6. The Trust is developing a specific risk register for CIP programmes where there are interdependencies between schemes, or aggregated and cumulative impacts. 3.3.7. The Trust has developed a standard recording tool and Standard Operating Procedure (SOP) which will be used by Divisions Clinical Governance and Risk Practitioners (CGRPs) on a quarterly basis to review progress with risk registers within Divisions. This was implemented from mid-january 2015 on a quarterly basis, with a briefing session and educational workshop with CGRPs held in early January. 3.3.8. A series of workshops for Divisional Management Teams was provided during January to March 2015 to refresh knowledge and understanding of Update on Quality Governance Framework Page 4 of 14
risk registers, the reporting and management of risk and the process of escalation. 3.3.9. A weekly risk management surgery takes place every Friday, providing staff with an opportunity to discuss any aspect of risk with a member of the Assurance Team. 3.3.10. The Board continues regularly to receive and discuss reports on Serious Incidents Requiring Investigation, including Never Events and actions arising from them [QC2015.25] 3.4. Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda? (2A) 3.4.1. The Board has remained stable since the Monitor assessment in September 2014 and its leadership, skills and knowledge are undiminished. 3.4.2. The Interim Medical Director was appointed to the substantive post in October 2014. In March 2015, Dr Clare Dollery commenced in post as full time Deputy Medical Director, with substantial experience in quality improvement, bringing additional high-level leadership and expertise to Board-level discussions. Dr Dollery is a full member of TME, and of the Quality Committee, to further emphasise the importance of the quality agenda. 3.5. Does the Board promote a quality-focused culture throughout the Trust? (2B) 3.5.1. Monitor s letter of 5 November 2014 on Quality Governance Framework findings was immediately distributed to Board members and considered at the Board s Part II meeting in November. The results were discussed by the Board as part of the Board Seminar in November 2014, and the Quality Committee considered a range of papers addressing Monitor s findings at its meeting in December 2014. 3.5.2. The Trust is working to build substantive workforce capacity through its actions on recruitment and retention. A revised multi-professional Education and Training Strategy has been commissioned through the Education and Training Committee for completion in March and agreement by the Board in May. This Strategy will address protected time for training and appraisals. 3.5.3. All Consultants job plans within the Trust include one session (PA) per week for activity with regard to revalidation, which includes quality improvement activity (such as the supervision of clinical audit), continuing professional development and time to prepare for appraisal. 3.5.4. The substantive Medical Director is now supported (from March) by a new full time Deputy Medical Director and an Associate Medical Director for Medical Workforce, increasing the capacity in the Medical Director s Office. Plans for the development of a Medical Engagement Strategy have been slowed down as the new members of the team take on their full portfolio case load. This will be progressed in late spring 2015. 3.5.5. The Board actively supported the Quality Strategy Implementation Plan events held in January 2015. In March, a session at the Board Seminar Update on Quality Governance Framework Page 5 of 14
was given over to an in-depth consideration of quality and organisational culture. This was also attended at the Board s request by Divisional Directors or their representatives. 3.6. Are there clear roles and accountabilities in relation to quality governance? (3A) 3.6.1. Following the review of the role and functioning of the Clinical Governance Committee (CGC), completed and reported to Trust Management Executive and the Quality Committee [QC2014.93 and TME2014.330], there is now a revised sub-committee structure, an escalation process clearly defined in the Terms of Reference of the CGC and each of its subcommittees, and a clear link between goals in the refreshed Quality Strategy and the objectives of relevant CGC sub-committees. 3.6.2. Dr Clare Dollery commenced as full-time Deputy Medical Director on 1 March 2015, and has taken over Chairmanship of the Clinical Governance Committee. Dr Dollery is a full member of TME and the Quality Committee to further emphasise the importance of the quality agenda. She is supporting the development of the new Clinical Effectiveness subcommittee of the CGC, which is chaired by the Associate Medical Director for Medical Workforce and Engagement. 3.6.3. The Board lead for Quality remains the Medical Director, and the lead for the Patient Experience domain of quality remains the Chief Nurse. 3.7. Are there clearly defined, well understood processes for escalating and resolving issues and managing quality performance? (3B) 3.7.1. At its meeting on 27 November 2014, the Trust Management Executive received and discussed a review of the policies and practices for escalating issues to quality performance. The committee approved the proposed changes to relevant policies to strengthen the processes for escalation [TME 2014.298]. 3.7.2. The paper reinforced the importance of early reporting of incidents by clinicians, according to NHS England s framework for escalation of incidents according to their severity. 3.7.3. The Quality Committee discussed and endorsed the revised approach at its December meeting [QC2014.86] 3.7.4. An enhanced training programme commenced from 1 February 2015, with workshops held with Clinical Governance Risk Practitioners working in the Divisions. A nursing Grand Round has been presented dealing with serious incidents and escalation pathways. 3.7.5. A standardised reporting template for escalation issues has been implemented. 3.7.6. There has been discussion at TME and at CGC regarding the new escalation framework and the implications and consequences of this. Improvements in performance times for the declaration of serious incidents have been considerable and are described in QC2015.25 considered at the April 2015 meeting of the Quality Committee. 3.7.7. Coincident with this work on escalation, a number of Never Events have been declared since October 2014. All have been escalated to the Board Update on Quality Governance Framework Page 6 of 14
and considered in Board and Quality Committee papers. Reporting times have improved for the Never Events as well as for other SIRIs, as described in Quality Committee report [QC2015.25]. 3.7.8. The implications of the Never Events in the context of overall mortality and harms, and of work to build a universally open and just culture, were also considered at a Trust Board Seminar session on quality held in March 2015 with Divisional representation. 3.7.9. The Quality Bulletin newsletter process was reactivated in January 2015. Work is ongoing to ensure an optimal style and content for sharing learning across the organisation. 3.8. Does the Board actively engage patients, staff and other key stakeholders on quality? (3C) 3.8.1. The Board continues to engage patients, staff and stakeholders on quality as previously described in the full QGAF document. 3.8.2. In January 2015 Board members hosted and attended two large-scale workshops on the Quality Strategy and Implementation Plan, which were used to inform the plan and the 2015-16 quality priorities as set out in the Quality Account [QC2015.23] 3.8.3. Following the election of the Board of Governors, a training and induction programme is underway to ensure this key group is fully inducted including into quality issues, and is engaged with the Board. 3.9. Is appropriate quality information being analysed and challenged? (4A) 3.9.1. The Board Quality Report and the Integrated Performance Report present quality information to the Trust Board monthly regarding: The delivery of national targets; Safe staffing levels Nursing sensitive quality indicators Other Trust-wide quality indicators Key Division-specific indicators of high importance Patient experience metrics 3.9.2. The two most recent Board Quality Reports, considered at the April 2015 Quality Committee meeting [QC2015.24] and the May Trust Board [TB2015.48], demonstrate the current state of data presented including many metrics that are shown at Divisional as well as Board level. 3.9.3. A full listing of other quality metrics is beyond the scope of this document and remains as set out in the full QGF document. 3.9.4. Further review and development of quality metrics is planned during 2015-16 linked to work to establish a Trust performance information unit (see overleaf). Update on Quality Governance Framework Page 7 of 14
3.10. Is the Board assured of the robustness of the quality information? (4B) 3.10.1. The Board is assured of the quality of its performance management data by means of data quality structures and a data quality strategy supported by appropriate policies and procedures. An Information Governance and Data Quality Group (IGDQG) meets bi-monthly and reports to the Health Informatics Committee, a sub-committee of the Trust Management Executive; each Division has a corresponding group which reports to the IGDQG. 3.10.2. Each IPR indicator is assigned a rating of 1-5 based on the level of assurance obtained and a Red/Amber/Green rating to indicate the level of confidence in the indicator based on the available level of assurance. All indicator ratings and supporting evidence are held on the Trust s HealthAssure system. Each indicator owner is required to review the data quality of their indicators on a quarterly basis. The rating given to each indicator is reviewed annually by the IGDQG. 3.10.3. A full briefing on data quality issues was brought to the Trust Board in January 2015 [TB2015.11]. Further updates will be included in six-monthly information governance updates to the Board which have been incorporated into the cycle of business agreed at the Trust Board in March 2015 [TB2015.38]. 3.10.4. The Board s Audit Committee receives external and internal audits relating to data quality. External audit of the Trust s Quality Account takes place each year and includes substantive testing of sample quality indicators. The latest audit of the Quality Account by the Trust s external auditors was considered by the Board s Audit Committee at its September meeting as paper AC2014.50. The Trust s internal auditors review data quality on an annual basis. This was last reported to the Board s Audit Committee in April 2014, giving the Trust an overall rating of Significant Assurance. External audit of the 2014/15 Quality Account commences in mid-may as set out in the draft Quality Account [QC2015.23]. 3.10.5. Benchmarking is undertaken at each IGDQG meeting of the Trust s data quality using the national Secondary Users Service data quality dashboard. The Trust s performance is benchmarked both against national performance levels and against local comparator Trusts. 3.10.6. A Clinical Audit Annual Report was considered by the Board s Audit Committee in November 2014 [AC2014.69]. This set out categories of audit required of each Division as a result of the Trust s Clinical Audit Strategy, including all relevant National Clinical Audits as defined by the Healthcare Quality Improvement Partnership (HQIP). The Annual Report explained that in 2013/14, 65 mandatory and 176 non-mandatory audits were undertaken by the Trust s Divisions and that during the year, OUH participated in 100% of the national clinical audits and 100% of the national confidential enquiries in which it was eligible to participate. 3.10.7. The draft Quality Account for 2014/15, reviewed at the April meeting of the Quality Committee [QC2015.23] identifies 48 national clinical audits and three national confidential enquiries covered relevant services that Oxford University Hospitals NHS Trust provides. During that period the Trust participated in 100% of the national clinical audits and 100% of the Update on Quality Governance Framework Page 8 of 14
national confidential enquiries in which it was eligible to participate. Also in 2014/15, the Trust undertook over 280 (10/3/15) registered local clinical audits. Thus in total, the number of registered audits undertaken rose from 241 in 2013/14 to 331 in 2014/15. 3.10.8. At its November meeting, the Audit Committee asked the Medical Director s office to consider the balance of local and national audit input and the effectiveness of the clinical audit programme. This work was expected to be undertaken by the Deputy Medical Director who commenced in post in March 2015, and whose proposed approach for the review of the clinical audit strategy was presented to the Audit Committee in April 2015 [AC2015.32]. 3.10.9. Based on the Monitor feedback regarding the resources available to undertake clinical audit, the Medical Director and Director of Clinical Services undertook to review the adequacy of resources in relation to clinical audit. The update was provided to TME in April 2015 [TME2015.103] as previously discussed in Audit Committee [AC2015.32]. 3.11. Is quality information being used effectively? (4C) 3.11.1. OUH participates in a wide range of benchmarking activities, but recognises that benchmarking information needs to be presented to the Board using a wider group of peers than the Shelford Group of teaching hospitals, and that national benchmarking is more visible to Board members. 3.11.2. By the end of March 2015 the Trust aimed to develop a programme of work to review all existing reports and the benchmarking data used within them to provide assurance to the Board. The programme was to be implemented from April 2015. 3.11.3. The Trust Executive and Board has agreed to develop a dedicated performance information unit to coordinate, quality assure and deliver performance information to the Board. 5. Discussion on scorings. 5.1. Appendix 1 (attached) shows changes in the QGF scores over time. Noteworthy increases in scoring (worsening in rating) accompanied external assessments from RSM Tenon in October 2012 and Monitor in November 2014. 5.2. The scoring matrix and this paper were discussed at TME in April, with the various scores examined and challenged. TME was assured by evidence of improved governance as set out in this paper and the supporting papers underlying it. On that basis, TME recommended the following: No. Proposal Revised score 1a A reduction in the score of 0.5 to 0.0 relating to quality driving 0.0 Trust strategy 1b Maintenance of the score for Board awareness of risk; 0.5 improvements in escalation of concerns and incidents being partly offset by the multiple Never Events 2a Maintenance of the score for Board leadership 0.0 2b Maintenance of the score assessed by Monitor for promotion of a 0.5 Update on Quality Governance Framework Page 9 of 14
No. Proposal Revised score quality culture, also due to the impact of the Never Events 3a A return to a score of 0.0 for roles and responsibilities 0.0 3b A reduction from 1.0 for the score on escalation processes 0.5 3c Maintenance of the score for engagement with patients, staff and 0.5 stakeholders 4a Maintenance of the score for Board challenge and analysis of 0.0 quality information 4b A reduction from 0.5 to 0.0 for Board assurance of the robustness 0.0 of quality information 4c A maintenance of the score for effective use of quality information 0.5 6. Evidence Review Total proposed score 2.5 6.1. In addition to the evidence listed in the body of this paper the Assurance Team are in the process of collating a refreshed evidence base to support the selfassessment results. A full list of the supporting evidence available to provide to Monitor is attached at Appendix 2, for information. 7. Recommendation 7.1. The Trust Board is asked to: note the progress made in Quality Governance; and Consider whether the evidence presented justifies the favourable movement in the QGF scores, from those previously determined by Monitor, to those proposed by TME. Dr Tony Berendt, Medical Director May 2015 Update on Quality Governance Framework Page 10 of 14
Appendix 1 Appendix 1: OUH Quality Governance scores, 2012-2015 Strategy Jul 2012 OUH Selfassessment Oct 2012 RSM Tenon Score Dec 2012 OUH Selfassessment April 2013 OUH Selfassessment May 2014 OUH selfassessment and KPMG Monitor November 2014 1a. Does quality drive the trust s strategy? 0.5 0.5 0.0 0.0 0.0 0.5 0.0 1b. Is the Board sufficiently aware of potential risks to quality? 0.5 0.5 0.0 0.0 0.0 0.5 0.5 Capability and Culture 2a. Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda? 2b. Does the Board promote a quality-focused culture throughout the trust? Processes and Structures 3a. Are there clear roles and accountabilities in relation to quality governance? 3b. Are there clearly defined, well understood processes for escalating and resolving issues and managing quality performance? 3c. Does the Board actively engage patients, staff and other key stakeholders on quality? Measurement 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.5 0.5 0.0 0.0 0.5 0.5 0.0 0.5 0.5 0.5 0.0 0.5 0.0 0.5 0.5 0.5 0.5 0.5 1.0 0.5 0.0 0.5 0.5 0.5 0.0 0.5 0.5 4a. Is appropriate quality information being analysed and challenged? 0.5 0.5 0.5 0.5 0.5 0.0 0.0 4b. Is the Board assured of the robustness of the quality information? 1.0 0.5 0.5 0.5 0.5 0.5 0.0 4c. Is quality information being used effectively? 0.5 0.5 0.5 0.5 0.5 0.5 0.5 Total 4.0 4.5 3.5 3.0 2.0 4.5 2.5 OUH selfassessment, April 2015 Update on Quality Governance Framework Page 11 of 14
Appendix 2 Primary Evidence Title QGF Question 1a.1 Annual Business Plan (s) Divisional 1a.1 CEO and Team briefs 1a.1 CQC Reports 1a.1 Directorate quality posters 1a.1 Integrated Business Plan 1a.1 Minutes of Clinical Governance Committee 1a.1 Minutes of Divisional meetings. 1a.1 Performance Meeting letters 1a.1 QIA for CIPS 1a.1 Quality Account 14/15 1a.1 Quality Committee Report 1a.1 Quality Matters newsletter 1a.1 Quality Reports (e.g. to Quality Committee) 1a.1 Quality Strategy/ Implementation plan. 1a.1 TME Papers updating progress with regard to peer review 1a.1 TME Papers updating progress with regard to risk summits 1a.2 Divisional quality Priorities 1a.2 Divisional Quality Reports 1a.2 Dr Foster reports and alerts 1a.2 Integrated Performance report 1a.2 National and local patient experience surveys & stakeholder events 1a.3 Action Plans after Executive walk rounds plus examples of posters 1a.3 Business Plans - Divisional 1a.3 Contract Review Meeting Agenda 1a.3 Corporate Risk Register Report 1a.3 Dr Foster reports and alerts 1a.3 Example of quality improvement initiatives 1a.3 Minutes of patient engagement event on quality priorities 1a.3 National Audit reports via web link in Intranet 1a.3 Patient involvement groups - attended by board 1a.3 Staff Surveys 1a.4 Staff suggestion scheme 1a.4 Stakeholder events 1a.5 Divisional Governance Minutes 1a.5 Outputs of ORBIT data warehouse 1a.5 Quality Posters 1a.6 Bi annual report to Board 1a.7 Example emails global emails re quality 1a.7 Intranet / Internet - Re Quality Updates 1a.7 LIA Programme 1a.7 OUH news 1a.8 Board Minutes 1a.8 Patient story programme for Board 1a.8 Terms of Reference to Quality Committee - current version not 1b.1 Annual Complaints Reports - timing 1b.1 Attendance register demonstrating attendance by Board members re Risk summit 1b.1 BAF and CRR Board papers 1b.1 CIP template - 1b.1 Divisional and Directorate Quality Posters (Examples of posters) 1b.1 Examples of completed QIA 1b.1 Outpatient re-profiling project 1b.1 Patient story programme for Quality Committee 1b.1 Terms of Reference Audit Committee 1b.10 CIP information on Intranet Update on Quality Governance Framework Page 12 of 14
Primary Evidence Title QGF Question 1b.10 CIP process document. 1b.10 CIP Report for Quality Committee 1b.10 CIP summary sheet 1b.11 Action taken from feedback - whistleblowing and raising concerns 1b.11 CGC agendas 1b.11 Workforce Committee Minutes 1b.3 Examples of Divisional and Directorate Risk Registers 1b.4 Minutes of TAG reported to Clinical Governance Committee 1b.6 Business Planning Guidance 1b.6 Example Business Cases 1b.7 Endoscopy efficiency project 1b.7 NPSA six monthly organisational incident 1b.7 Template for business cases 1b.9 Example of Service improvement project 2a.1 Clinical Governance Committee minutes reported to Quality Committee 2a.1 Infection Control Annual Report to Quality Committee 2a.1 Internal Audit Plan 2a.1 Prevention of Future Death Annual Report 2a.1 Safeguarding Annual Report to Board 2a.2 Board Development programme 2a.2 Board membership breakdown and biographies 2a.2 Example of Board Seminar Agenda 2a.3 Report Update to Board on Cardiac Surgery 2a.4 Discharge Improvement Plan 2a.4 End of Life Business Case 2a.4 End of Life Seminar 2a.5 Board Report on Committee Effectiveness 2a.6 Examples of Board Away Days 2b.1 Clinical Governance Committee Terms of Reference 2b.1 Healthcare for All Reports 2b.1 Ombudsman (PHSO) summary reports 2b.2 Obstetric investment 2b.2 Supported Hospital Discharge Service 2b.3 Patient Experience Strategy 2b.3 PLACE reports to the Quality Committee 2b.3 Quarter 4 OD & Workforce Performance Report 2b.6 Series of service improvement team projects 2b.6 Examples of committees monitoring action plans 2b.6 Examples of service improvement projects at Divisional level 2b.6 Minutes for TME 3a.1 Divisional Executive Meetings (DME) 3a.2 Board agenda 3a.4 Effectiveness review reports 3b.2 Incident reporting policy 3b.2 Quality Committee SIRI paper(s) 3b.3 Action plans from SIRIs 3b.3 Cardiac action plan 3b.3 Complaint action plans 3b.3 Patient Safety and Clinical Risk Committee minutes 3b.4 Examples of outputs from SIRI closure meetings 3b.5 Annual Clinical Audit Report to Clinical Audit Committee 3b.5 Annual Clinical Audit Report to Quality Committee 3b.5 Clinical Audit Committee Terms of Reference 3b.5 Clinical Audit Plan 3b.5 Clinical Audit reports to Clinical Governance Committee 3b.5 Internal Audit Reports to the Audit Committee Update on Quality Governance Framework Page 13 of 14
Primary Evidence Title QGF Question 3b.6 Clinical Audit Procedure 3b.6 Clinical Audit Strategy 3b.6 Minutes of Clinical Audit Committee 3b.8 Clinical Governance Organisational Structure 3b.8 Staff Recognition schemes 3b.9 Emergency Department Paediatric Transfer Protocol 3b.9 Home for Lunch 3b.9 Length of Stay project 3b.9 Pharmacy project 3c.1 Learning Disability Partnership Group 3c.2 Board Reports (public) 3c.2 Chief Executive briefings 3c.3 Quarterly Complaints Report 3c.5 DTOC groups 3c.5 Health Overview and Scrutiny Committee 3c.5 Maternity Services Liaison Committee 4a.3 Committee Structure chart 4a.4 Electronic patient record 4a.4 Medical Appraisal Policy with local requirements 4a.4 Minutes of coding meetings 4a.7 Dr Foster reports to Clinical Governance Committee 4a.7 Specialist Commissioning Dashboards 4a.8 Data Quality Group Terms of Reference 4a.8 Internal audit of quality of data 4a.8 Minutes from Data Quality Group 4b.2 Minutes of Divisional data quality groups 4b.6 Annual External Audit PbR review 4b.6 Clinical coding good practice guide 4b.6 Clinical Coding top tips guide 4b.6 Example minutes of coding meetings 4c.4 Medicines reconciliation data 4c.4 CQC Outlier information Update on Quality Governance Framework Page 14 of 14