Quality and Governance Committee Terms of Reference 1. Constitution 1.1 The Clinical Commissioning Group s Governing Body hereby resolves to establish a Committee of the Governing Body known as the Quality and Governance Committee. The Committee is established in accordance with South Gloucestershire Clinical Commissioning Group s Constitution, Standing Orders and Scheme of Delegation. 1.2 These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the CCG s constitution. 2. Purpose 2.1 To report to the Governing Body on the development, implementation and monitoring of integrated governance by providing assurance on: Systems, processes and behaviours by which trusts lead, direct and control their functions in order to achieve organizational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations. (Dept of health, Integrated Governance Handbook for Executives and Non-executives in Healthcare Organisations February 2006) 2.2 Provide assurance to the Governing Body that there are robust and effective structures, processes, and accountabilities in place for identifying and managing risks in commissioned services (i.e. strategic, operational, clinical and organisational). 2.3 Ensure the principles of good governance are embedded in the management and discharge of its responsibilities as a corporate entity. 2.4 Ensure there are mechanisms in place to share learning and good practice in order to raise standards. 2.5 To provide assurance that all services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything the clinical commissioning group does. 1
2.6 To ensure the principles of all aspects of quality assurance and governance (excluding financial governance) are integral to performance monitoring arrangements for all CCG commissioned services and are embedded within consultation, service development and redesign, evaluation of services and decommissioning of services. 2.7 To oversee the development and implementation the CCG Quality Strategy and Quality Board Assurance Framework. 2.8 To seek assurance that patients have effective and safe care with a positive experience of services and receive intelligence from a number of sources to support this. 2.9 To seek assurance that the CCG is fulfilling its statutory duties for equality and diversity, particularly the Equality Act 2010, through the implementation of the Equality Delivery System. 3. Responsibilities 3.1 The Quality & Governance Committee oversees the systems and processes for clinical governance; quality performance reporting; equality duty, corporate governance; contracting and commissioning governance: workforce governance; research governance; and information governance on behalf of the Governing Body. 3.2 Provide assurance to the Governing Body: That the CCG meets all relevant statutory and regulatory obligations including the duty of quality set out in the Health and Social Care Act 2012. On the adequacy of systems for quality assurance, managing risk, and the control of the environment, including the sustainability programme. That the Governing Body has an effective Corporate Risk Register, Risk Management Strategy, and Assurance Framework. 3.3 To provide assurance to the Board that CCG s assurance framework and corporate risk register is comprehensive and robust. The Quality and Governance Committee will also advise the Governing Body on acceptable risk. In discharging both these duties the Quality and Governance Committee will: Review individual assurance gaps and risks, Authorise additions and removals 2
Decide whether to accept the risk or assurance gap Determine whether to assign responsibility for consideration of additional controls Determine if the matter should be referred to the Governing Body for decision. 3.4 Identify and determine best performance, quality and value outcomes by assessing clinical effectiveness, cost effectiveness, quality standards and the views of patients and carers in South Gloucestershire. 3.5 Maintain a mechanism for working in partnership with NHS England to improve the quality of primary medical care. 3.6 Seek assurance that the commissioning plans for the Clinical Commissioning Group fully reflects all elements of quality (patient experience, effectiveness and patient safety), keeping in mind that the Commissioning plans and responses may need to adapt and change. 3.7 Advise and develop locally sensitive quality indicators in order to continually improve the quality of services. 3.8 Ensure all service development and redesign, evaluation of services and decommissioning of services are subject to Quality Impact Assessment. 3.9 Have oversight of the process and compliance issues concerning serious incidents (SIs); being informed of all Never Events and informing the Governing Body of any escalation or sensitive issues in good time. 3.10 Implement key standards in relation to Information Governance (including the Information Governance toolkit, data exchange agreements, etc) and ensure effective governance systems are in place for implementing and monitoring these standards. 3.11 Receive regular patient safety, patient experience and complaints reports to review themes and trends and identify areas for recommending change in practice. 3.12 Seek assurance that effective processes are within provider organisations and the CCG for safeguarding children and young people, safeguarding vulnerable adults, domestic violence, forced marriage and the PREVENT agenda. 3
3.13 Implement recommendations and actions following national inquiries and national and local reviews undertaken by external agencies and local strategic partnerships (e.g. CQC, LSCB/LSAB Internal Audit). 3.14 Seek assurance on the performance of NHS organisations in terms of the Care Quality Commission, Monitor and any other relevant regulatory bodies. 3.15 Receive and scrutinise independent investigation reports relating to patient safety issues and agree publication plans. 3.16 Oversee and be assured that effective management of risk is in place to manage and address clinical governance issues. 3.17 Ensure a clear escalation process, including appropriate trigger points, is in place to enable appropriate engagement of external bodies on areas of concern. 3.18 Receive and approve corporate governance policies on behalf of the Governing Body. 3.19 To consider procurement proposals as delegated by the Governing Body. 4. Membership 4.1 The membership of the Quality and Governance Committee will be: Lay Member of the Governing Body Committee Chair GP Clinical Governance Member of the Governing Body Chief Officer (Vice Chair) Director of Operations Director of Nursing and Quality Deputy Chief Financial Officer Head of Governance and Quality Research Lead Corporate Support Officer Head of Medicines Management 4.2 Membership will be reviewed regularly to adjust for changes in the purpose of the Committee. 4.3 A representative of the local Commissioning Support Service will be asked to be in attendance for relevant items. 4.4 Members who cannot attend may, with the agreement of the Chair, send a named deputy. Deputies will have the decision-making and voting rights of the person he/she is representing. 4
4.5 A decision put to a vote at the meeting shall be determined by a majority of the votes of members and deputies present. In the case of an equal vote, the Chair of the Committee shall have a second and casting vote. 5. Quorum 5.1 A minimum of four members will constitute a quorum, so long as this includes either the Chair or Vice Chair of the committee, either a GP or the Head of Medicines Management, and either the Head of Governance and Quality or the Director of Nursing and Quality. 6. Reporting arrangements 6.1 The minutes of the Quality and Governance Committee shall be formally recorded and submitted to the CCG Governing Body once approved. 7. Administration 7.1 Administrative support will be the responsibility of the Head of Governance & Quality and provided by the Corporate Support Officer or Team PA. 8. Frequency 8.1 The Quality and Governance Committee will meet on a quarterly basis and extraordinary meetings will be held as required. 9. Conduct of the Committee 9.1 The Committee shall conduct its business in accordance with national guidance, relevant codes of practice including the Nolan Principles and the Conflict of Interest policy. 9.2 An annual report on the Committee s performance, membership and terms of reference will be submitted to the governing body. 10. Review 10.1 These Terms of Reference will be reviewed on an annual basis, or sooner if required, with recommendations made to the CCG Governing Body. Reviewed by the Quality & Governance Committee: February 2016 Approved by the Governing Body: 27 th April 2016 Date of Next Review: February 2017 5