Board meeting date: 29 th May 2013 Agenda Item number:10.1 Enclosure:5 Title and Quality Committee Review Accountable Director: Author (name & title): Wendy Pugh Director of Operations and Nursing Rosie Musson - Head of Nursing, Quality and Innovation Tom Jinks - Action required from the Board: Decision / Approval X Gain assurance Discussion Information What other Trust Committee or Group has considered this report? Committee & Quality Date reviewed 15/05/2013 Key points or recommendations That the Trust Board support the changes set out in the paper. Purpose of the report To inform the Board of the proposed changes to the Trust and Quality Committee (G&Q) and to seek Board approval for the implementation of these changes. Summary of Key Issues and Risks for Board Attention The key issues that the board needs to consider in this report are: The Trust Board previously agreed that in light of internal and external drivers it would be an appropriate time to review the Trust s Quality arrangements, and in particular the role and remit of the and Quality Committee. This Paper sets out the proposals which were subject to discussion and agreement at a and Quality Committee re-focus session on 15 th May 2013. The proposed changes will: Enable enhanced discussion and challenge at and Quality Committee regarding key quality and governance issues. Page 1 of 13
Ensure that the Trust is meeting National Best Practice recommendations arising from the Francis and Winterbourne Inquiries. Seek to address feedback received from external assessors during the recent Monitor assessment process. Enhance the reporting of quality information and governance issues to Board providing greater assurance from service lines The key risks are: Additional committee time to allow for more in depth discussions and challenges to occur. Increased contribution to the committee agenda by Heads of Service and Clinical Directors. Recommendation(s) to Board The Board is asked to consider the proposals and approve the actions/recommendations identified by the G&Q committee. Strategic Objective(s) to which this paper relates: High quality services Inclusive partnerships Leadership culture Responsible workforce Supporting strategies Effective & efficient resources / Does this paper raise any Issues which are especially relevant to any of the following? Board Assurance Framework CQC Equality & Diversity Financial issues (revenue & capital) NHSLA OD/Workforce Patient safety & experience Patient & public involvement If so please explain in more detail Page 2 of 13
Title Proposal for the Revision of the Trust and Quality Committee Executive Summary The and Quality Committee has been a Sub Committee of the Trust Board since the formation of the Trust in 2008. The committee has a delegated Trust Board responsibility for the effective management and oversight of risk management, patient safety, clinical governance and quality enhancement. The Trust identified the need to review the functioning of the Committee in light of local and national quality and governance drivers. The Trust Board supported the review and tasked the committee with brining recommendations back for approval to May Trust board. The review has taken into consideration external feedback from a number of independent assessments carried out as part of the Foundation Trust application process together with learning from the Frances and Winterbourne Inquiries. The purpose of this paper is to present to the Board the actions and recommendations identified by the Committee and the proposed revisions to the terms of reference. Context/Background The and Quality Committee (G&Q) has been in existence since the inception of the Trust in 2008. During that time it has changed and evolved to meet the emerging needs of the developing organisation as became established and adapted to the changing landscape and priorities. The and Quality Committee remit and function has been subject to much independent scrutiny over the previous 2 years as the Trust progressed its Foundation Trust application. These assessments concluded that the Committee was meeting the requirements and standards set out in both the Board Assurance Framework and the Quality Assurance Framework as well as the Due Diligence assessments. However as part of its internal review process, the Board identified that the present format of the Committee should to be reviewed and refocused to ensure that it would continue to develop and enhance the Trusts Quality arrangements. In addition, the Committee Chair (Peter Hodnett, Non-Executive Director) recently announced his retirement from the Trust triggering the need to appoint a new chair for the committee. At the April Board meeting it was agreed that it would enhance the Committee if the successor was to have a strong clinical background. Having identified the requirement to review and refresh the committee focus the Trust has: Page 3 of 13
Reviewed BGAF and QGAF feedback from independent assessors Considered the lessons leant from the Francis & Winterbourne Inquiries at the Board Away Day on 28 th March Enhanced reporting to the G&Q Committee Conducted a series of Hear & Now s reviews to monitor quality performance in relation to service transformation Undertaken a Board refocus session on 24 th April 2013 Appointed a designate Clinical Director for and Quality Appointed a new Chair for the and Quality Committee at the April Trust Board meeting. Introduced a programme of Board and Senior shadowing called New Persectives Proposed that each Non Executive Director take a specific interest in an individual service line by becoming a sponsor.. These actions culminated in a dedicated and Quality Committee review session held on the 15 th May 2013 from which a series of recommendations and actions have been identified and are presented to the Trust Board for approval. Key issues/options available The review of the and Quality (G & Q) Committee review session primarily focused on the following key areas: What elements were currently working effectively and the Committee s achievements to date. How the committee would drive Quality and provide assurance to the Trust Board. The number, attendance and effectiveness of the current membership including service line accountability and involvement. Whether the appropriate quality information was being analysed and challenged including quality and risk impact of CIP/ST schemes. The Sub group/committee structure and reporting arrangements into G&Q. Effective monitoring of CQC essential standards and compliance with the Quality Framework. That action plans will fully address issues/lessons learned, be time bound, followed up and the impact of actions reviewed. Increased use and understanding of national, regional and local benchmarking material. Ensuring that Trust Quality goals are effectively linked to staff appraisals and objectives in order to assist with the delivery of the goals. The recommendations identified by the committee are: 1. That the Committee membership be reduced and refocused to include senior managers with key accountabilities (membership set out in revised Terms of Reference appendix 2) Page 4 of 13
2. Meetings would continue to be held monthly, but once a quarter there would be an extended Enhanced G&Q Meeting where service line leads would attend to present quality information/issues, share good practice and discuss future service strategy. 3. Meeting agendas will be improved to allow greater time for discussion, challenge and debate, including a regular single issue focus item. 4. Information presented to the committee will be improved both in terms of detail and analysis/ triangulation, and include wider performance information including operational delivery, financial and workforce information. 5. To ensure more effective alliance of clinical and internal audit programmes to the Trust s quality priorities. 6. The Committee will agree the quality priorities and objectives with each service line and monitor achievement through the quarterly enhanced G&Q spotlight sessions. 7. The Committee will establish its own annual reporting schedule aligned to local and mandatory requirements and the Trust Board annual business plan. A detailed action plan aligned to the Monitor Reactivation Action Plan is included at appendix 1. Board action required The Board is asked to approve the actions/recommendations identified by the G&Q committee. The Board is asked to agree the revised Terms of Reference. Page 5 of 13
Appendix 1 Implementation Action Plan Action Tasks Target Date Lead(s) Intended Impact Review Terms of reference in line with Terms of reference review recommendations to be re-drafted Terms of Reference to be approved by Trust Board May 2013 Tom Jinks Rosie Musson Head of Nursing, Quality and Innovation New terms of reference will accurately reflect revised committee remit and provide clarity to committee members Sources of Assurance G&Q revised Terms of reference G&Q Minutes Board Minutes Revised membership to be implemented Trust Board to agree proposed membership May 2013 Robin Gutteridge Chair of G&Q Committee Smaller core membership of G&Q committee G&Q revised Terms of reference G&Q Minutes The agenda process to be linked to monthly. quarterly, bi annually and annually Chair, Executive Directors, and Head of Nursing Quality and innovation to develop revised agenda format and annual committee reporting schedule June 2013 Robin Gutteridge Chair of G&Q Committee Enhanced Agenda that will allow more time for discussion and challenge G&Q revised Agenda Template and annual reporting schedule Page 6 of 13
Action Tasks Target Date Lead(s) Intended Impact Ensure each sub group has an agreed June 2013 Chairs of Sub annual work plan and fulfils reporting Groups schedule requirements. Agree service line quality profiles. Metrics and reporting schedule Agreement of annual sub group objectives based on Trust annual objectives / quality priorities to be developed. Agreement of reporting requirements and formats Agree with each Head of Service the service line quality profiles, the service line specific quality metrics and reporting schedule and requirements with a particular emphasis on quarterly service line enhanced G&Q spotlight meetings June 2013 Tom Jinks - Rosie Musson Head of Nursing, Quality and Innovation Heads of Service Wendy Pugh - Director of Operations and Nursing Rosie Musson Head Nursing, Quality and Innovation Tom Jinks - Effective reporting arrangements to G&Q from Sub groups Clearly defined sub group objectives Clear Quality Metrics and service line profiles will allow for a clear focus on priorities and outcomes in each service line enabling the Head of Service to appropriately direct resource and flag any areas of concern / best practice Sources of Assurance Sub Group reports Documented sub group objectives Agreed Service line metrics Agreed Service line Reporting schedule Service line quality profiles and objectives Page 7 of 13
Action Tasks Target Date Lead(s) Intended Impact Agree extended quarterly meetings to be Establish Meeting June 2013 Heads of attended by HOS and CDs meeting schedule and Service focus to include quality profiles, metrics, arrange meetings risks and mitigations Determine agenda items and timings of meeting Invite required attendees Wendy Pugh - Director of Operations and Nursing Tom Jinks - Quarterly in depth reviews of service line issues and outcomes enabling a Board to ward and ward to Board flow of key quality information to occur Sources of Assurance Minutes of Quarterly G&Q service line meetings G&Q reports to Board. Spot light sessions focusing on specific trends and concerns to be included on G&Q committee agenda Agree spotlight topics Produce data / reports to inform discussions June 2013 and ongoing Rosie Musson Head of Nursing, Quality and Innovation Heads of Service Wendy Pugh - Director of Operations and Nursing Tom Jinks - Board is fully informed of all quality issues / risks / concerns / successes Allow specific agenda time to focus on one key quality area per month and enable challenges and action to be taken to be agreed at committee G&Q Minutes and Agendas G&Q reports to Board. Rosie Musson Head of Page 8 of 13
Nursing,Quality and Innovation Action Tasks Target Date Lead(s) Intended Impact Trust Policy review and ratification Review process process to be reviewed Revise process Seek Board approval June 2013 Tom Jinks - Streamlined ratification process allowing for speedier ratification of key policies Sources of Assurance Paper to Board detailing proposed new policy ratification process Review process for monitoring of actions plans Implement new process Review process Revise process Seek Board approval Implement new process June 2013 Wendy Pugh - Director of Operations and Nursing Tom Jinks - Reduce agenda time for policies on G&Q agenda Closer monitoring of actions and greater Board assurance that recommendatio ns / suggested actions are being fully embedded across the Trust Paper to Board detailing proposed new process for monitoring key action plans / action implementation Page 9 of 13
1. Purpose: DUDLEY AND WALSALL MENTAL HEALTH NHS PARTNERSHIP TRUST GOVERNANCE AND QUALITY COMMITTEE TERMS OF REFERENCE To oversee the implementation and monitoring of the Dudley and Walsall Mental Health Partnership NHS Trust governance and quality arrangements. In so doing, to seek and provide assurance to the Trust Board on the systems and processes by which the Trust leads, directs and controls its functions in relation to achieving the highest levels of service safety and quality outcomes. The committee has delegated responsibility from the Trust Board to oversee the management of risk within the organisation. 2. Accountability: The and Quality Committee is a sub-committee of the Trust Board. It is accountable for ensuring that robust and effective governance and quality arrangements are in place within the Trust and for providing this assurance to the Board. 3. Duties and Responsibilities: The Committee will review and maintain an effective system of governance, risk management and internal control across all of the Trust s activities both clinical and non clinical which supports the achievements of the Trust s objectives. In particular the and Quality Committee will: Monitor the assessment, compliance, assurances and evidence in support of key national evaluations and assessments, including CQC and NHSLA essential standards of quality and safety. Monitor the assessment of compliance, assurance and evidence against the Board Assurance framework (BGAF) Ensure that systematic opportunities for patient, carer and public participation are embedded in all Trust activities. Page 10 of 13
To be the lead committee for overseeing the development, implementation and monitoring of the Trust s Quality Strategy and supporting infrastructure, including the Quality Accounts and Quality enhancement priorities. Ensure compliance with relevant regulatory, legal and code of conduct requirements for Trust staff, especially in relation to: o Quality o Clinical o Research o Information To monitor the outcomes of external reviews, inquiries, surveys and investigations, and seek assurance that any lessons learnt have been considered and actioned where appropriate to ensure delivery of the highest quality services. To ensure that the Risk Management Policy and Principles are embedded and complied with across the Trust. To monitor the Trust s Risk Register and determine escalation of high level risks to the Board Assurance Framework. To monitor incidents, serious incidents, complaints, compliments and other patient experience feedback and ensure that appropriate action is taken, lessons are learnt and disseminated across all services. To ensure that there are appropriate systems in place for the development, ratification and systematic review of policies and procedures. To monitor quality metrics through receipt of the integrated performance dashboard and the service line reporting including benchmarking information. To receive and appropriately share examples of good quality and innovation Specifically, to monitor progress of the following working groups or sub-committees: o Health and Safety Committee o Infection Prevention Control Committee o Information and Risk Management group o Policies and Procedures Group o Service User and Carer Reference group o Audit and Effectiveness group o R&D group o Medicines Management Committee o Equality and Diversity group o Safeguarding Strategic group o Regulation and Risk group o Embedding lessons group o Service line and Quality groups Page 11 of 13
4. Membership: The following constitutes the core membership of the and Quality Committee: Non Executive Director - Chair Non Executive Director Vice Chair Chief Executive Director of People and Corporate Development Director of Operations and Nursing Joint Medical Directors Director of Finance, Information and Estates Head of Nursing Quality and Innovation Clinical Associate Director of Operations and Nursing Clinical Director and Quality Head of Performance Strategic Planning Head of Pharmacy Professional Leads Service User and Carer Representation/Governors Core members may nominate an appropriate deputy to attend the committee on their behalf. However, it is expected that any nominated deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising. Additional members or associates may be co-opted to attend the Committee as necessary. 6. Quorum The quorum for the and Quality Committee will be a minimum of six members and must include the chair or vice chair and at least one Executive Director. It is expected that members of the Committee will attend a minimum of six Committee Meetings each year and this will be monitored by the Committee Chair via the minutes and signing sheet. 5. Reporting The minutes of the Committee meetings shall be formally recorded and the ratified minutes will be submitted to the Trust Board. Sub groups will submit their minutes to the and Quality Committee and will report on progress on a monthly, quarterly or annual basis. Key issues will be reported by exception. Page 12 of 13
7. Frequency: The committee will normally meet on a monthly basis. As necessary, extra-ordinary meetings of the and Quality Committee may be arranged for specific purposes. The agenda and papers will be circulated to all members in advance of the meeting. Staff who are required to attend for specific agenda items will be invited by the Chair of the Committee and given a time allocation. Following each meeting, an action sheet will be circulated to members 8. Monitoring and Review The and Quality Committee will undertake an assessment of its overall effectiveness and compliance with these terms of reference at least annually. This review process will be in the form of a self-assessment checklist and will include the development of the following year s reporting cycle. The terms of reference will be formally reviewed by the and Quality Committee as part of this assessment. Any proposed amendments to the terms of reference will be ratified by the Trust Board. Page 13 of 13