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.
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;
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
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 email. 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.
Reviewed by: Q&S Committee Date: May 2016 Review date: May 2017
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.
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