Clinical Governance Framework Introduction Whanganui District Health Board (WDHB) is committed to continuously improving the safety and quality of services provided to patients and their families. This requires strong, transparent governance of all aspects of our clinical activities. Clinical governance provides a framework by which all staff, management and governors, led by clinicians, can be involved in contributing to improving patient safety and service quality. This document outlines the clinical governance arrangements in place at Whanganui District Health Board, both as a provider of health services and in its role of planning and funding services for the Whanganui district. Vision Whanganui District Health Board aims to achieve a culture of quality improvement whereby clinicians lead improvements in health care with a patient-centred strategy within available resources. The aims of our endeavours are to: improve the quality of patient care reduce risk and harm work as a team, whereby clinicians, managers, and governors are collectively accountable for decisions. Approach Whanganui District Health Board subscribes to Scully and Donaldson s 1998 concept of clinical governance as follows: Clinical governance is the framework through which health organisations are accountable for continuously monitoring and improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish Whanganui District Health Board also subscribes to the now widely agreed dimensions of quality, (Hurtado, Swift, and Corrigan 2001) these being: safety effectiveness appropriateness consumer participation access efficiency timeliness Whanganui District Health Board 1
Whanganui District Health Board accepts that services need to be planned for, and provided, within the context of finite resources. Whanganui District Health Board believes that providing safe, good quality service supports us to live within the resources that are available to us. We know the high costs that are incurred when services are provided below the expected standard. Whanganui District Health Board s approach to clinical governance is operationalised through: recognising and understanding the effects that human factors and systems errors will have on our services developing and using ways to monitor, measure and analyse the outcome of decisions and care using our understanding and information to provide clinicians, support staff, managers, and governors with the ability to contribute to service improvement. Structure, responsibilities and accountabilities Whanganui District Health Board considers that everyone involved with our organisation, whether it be as governor, manager, clinician, or a support staff member, has a responsibility to positively contribute to clinical governance. Our structure, and the high-level responsibilities and accountabilities to support the implementation of our clinical governance approach, is as outlined in this section and is shown diagrammatically in Appendix 1. Following are the key structural components with their responsibilities and accountabilities: Board of governors The board of governors has responsibility for creating the expectation of safe, good quality patient services and has responsibility for holding the chief executive accountable for meeting this expectation. Chief Executive, Executive Team, and other management staff The chief executive, Executive Team, and the other managers throughout the organisation, are accountable for ensuring that a culture of patient safety permeates the organisation, and that within their respective divisions, or areas of responsibility, there are appropriate standards in place, resources are available to enable staff to deliver to the expected standard, and that the systems are in place (and operational) to ensure adequate monitoring, measurement, and risk management. Clinical Board The Clinical Board has authority and influence throughout the organisation on all matters pertaining to patient safety and service quality. The Clinical Board s key responsibility is to maintain standards of practice, lead improvements in patient care and promote a culture of safety, quality and accountability. The Clinical Board reports directly to the chief executive. It provides advice to the board of governors, the chief executive and the management teams. The Clinical Board provides consistent and timely guidance to all key stakeholders. The Clinical Board represents Whanganui District Health Board on organisation-wide clinical and related matters. The Clinical Board has a formal link with the executive management team enabling direct communication and information sharing. Collaborative decision-making is an important feature of this relationship so that the Clinical Board and executive management team are equal partners in decisionmaking processes that affect or impact on patient safety and service quality. The Terms of Reference for the Clinical Board are attached as Appendix 2. Whanganui District Health Board 2
The clinical governance secretary fulfils the role of secretary to the Clinical Board. Committees, Professional and Service Reference Groups All staff and functions have a role in clinical governance. The comprehensive structure that supports the Clinical Board ensures there is a formal mechanism for all areas to raise concerns and make suggestions for improving patient safety and service quality. The committees and the professional and service reference groups also ensure that those aspects of clinical and non-clinical practice which are recognised as posing the most significant areas of risk for patients, staff and the organisation are identified and that management and the clinical leaders have appropriate monitoring and risk management strategies in place. Each member of the executive management team has responsibility as a sponsor or co-sponsor for a cluster of committees or professional and service reference groups and is accountable to the Clinical Board for the effective functioning of the cluster and for escalating the issues and/or opportunities of significance to the Clinical Board. The committees and the professional and service reference group clusters are: Professional Competence and Practice Improvement Clinical Risk and Patient Experience Clinical Services Improvement Support Services Improvement, Planning and Investment, and Organisational Risk Staff Health & Wellbeing The chairs of committees and the professional and service reference groups will be appointed by the Clinical Board with the agreement of the respective professional leader or general manager. Within the Professional Competence/Practice Improvement and the Clinical Risk /Patient Experience and the Clinical Services Improvement clusters, the chairs will be clinicians or have a clinical background. Each committee and professional and service reference group has a set of responsibilities, accountabilities, and key performance indicators outlined with the Terms of Reference established for their function. The Terms of Reference for each committee and the professional and service reference group are based on the principles of accountability, culture, and effectiveness and follow a standardised format as determined by the Clinical Board. The format includes membership, key responsibilities and accountabilities, key performance indicators, meeting times and frequency, and the reporting framework. The committee and the professional and service reference groups report to the Clinical Board using a standardised format. Reporting includes progress on annual objectives, responsibilities, and issues that have arisen and will include responsibilities for actions identified by the group. With the support of the Clinical Board, and defined terms of reference, the committees, professional and service reference groups have the authority to establish sub-committees or working groups with a direct reporting line to that committee or professional or service reference group. For example, a Medication Incident Reduction Committee (MIRC) and an Intravenous Therapy Committee may be established by and report to the Drug and Therapeutics Committee within the Clinical Risk and Patient Experience cluster. A further example is a Maternal and Perinatal Review Group reporting to the Mortality and Morbidity Committee. This process ensures a streamlined and interlinked clinical governance structure across all the district health board functions, services, professional and occupational groups. Whanganui District Health Board 3
The Clinical Board has responsibility for ensuring that at least every three years there is a stock take of the structural components, responsibilities, and accountabilities of our clinical governance structure to ensure the components are fit for purpose and are continuing to add value. Centre for Patient Safety and Service Quality The Centre for Patient Safety and Service Quality acts as the operational arm of the Clinical Board. The Centre has responsibility for co-ordinating the quality and risk activities and providing the Clinical Board, the clinical leaders and management with the formal linkages required to ensure the organisation is taking a co-ordinated approach to quality improvement. The Centre also has responsibility for contributing to the organisation s improvement priorities, strategies, and expectations being effectively communicated across all areas of our organisation, and supporting management to implement these. Systems and processes Supporting Whanganui District Health Board approach to clinical governance is a wide range of systems and processes. The major systems and processes that are integral to our clinical governance approach are: Human factors and systems errors Measuring monitoring and analysing Individual and systems improvements Complaints system Death reviews Professional standards Incident management Clinical audit Legislation and regulation Mandatory training Clinical supervision Credentialing Clinical pathways Clinical indicators PDRP, QLP Open disclosure Peer review Reflective practice Post event evaluations Performance framework Policy, procedure and guidelines To protect patient safety and the professional safety of the staff, WDHB has a comprehensive suite of policies and protocols that outline the rules for practising within our DHB. Staff are expected to adhere to the policies and protocols. Guidelines are also in place for a range of clinical matters to support staff to keep abreast of accepted best practice. Commitment The CEO and the professional leaders unequivocally support the vision and aims outlined in this document. However, the vision and aims can only become reality if every member of staff makes patient safety and good quality service their business. Please join us in making sure our patients have the best possible experience. Julie Patterson Sandy Blake Kim Fry John Rivers Chief Executive Director of Nursing Director Allied Health Chief Medical Officer & Patient Safety March 2015 Whanganui District Health Board 4
Appendix 1: The WDHB structure which supports the Clinical Governance Framework Board of Governors Hauora a Iwi CE Central Region Quality & Safety Alliance Ethics Committee Clinical Board EMT Regional Women s Health Professional Competence & Practice Improveme Clinical Risk & Patient Experience Clinical Service Improvement Support Services, Improvement, Planning & Investment, and Organisational Risk Staff Health and Wellbeing CMO/DON/DAH DON & Manager Patient Safety/ Director Maori Health/ Comms Manager CDs/NMs/AHM/ BMs GM Strategic & Corporate/ GM Business Planning & Support GM HROD Medical Credentialling Incident Medical Services Health Informatics Health & Safety Nursing PDRP Complaints Surgical Services Administration Advisory Group Union Forums Midwifery QLP Infection Women s Health Finance Medical Staff Association PUP & Wound Children s Health Buildings & Nursing Advisory Group Midwifery Advisory Group Allied Advisory Group Medical Audit Restraint Falls Clinical Communication Morbidity & Mortality Mental Health Older Person s Health Public Health Contracted out services Exceptional Circumstances/New Technologies Capital Investment Product Evaluation Nursing Audit Patient/Family Advisors Service Planning Hospitality Services Patient Information Drug & Therapeutics Director Maori Health Tools, Training, Data Analysis, Project, Quality PERFORMANCE FRAMEWORK Whanganui District Health Board 5
Appendix 2 Whanganui District Health Board Clinical Board Terms of Reference 1. Purpose/Roles/Responsibilities The Clinical Board s (CB) key purpose and responsibility is to lead all clinical governance activities occurring within Whanganui DHB. Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. Its most widely cited formal definition describes it as: A framework through which health organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. 12 The CB will fulfil its responsibility by setting direction and strategy, and monitoring performance of each of the significant components of Whanganui DHB s clinical governance framework, which are outlined as follows: The CB will undertake the following responsibilities: i. Monitor, safeguard, and influence clinical performance Oversee the processes for assessing the organisation s internal compliance, including certification and accreditation. Lead the expectation to continually improve and raise the standard of patient care and patient experience. Provide clinical input and advice to support service improvement committees and continuous improvement activities across the organisation. Support and encourage evidence-based approaches to clinical care. Ensure there are robust processes in place for assuring the competence of all clinicians and departments within Whanganui DHB through activities such as Medical Credentialing. Monitor compliance with the Credentialing Policy and the findings of credentialing reviews, and ensure required improvements are made where necessary. Monitor clinical systems and standards to ensure that the care delivered is safe and evidenced-based. Ensure the provision of tools to support mortality and morbidity reviews. Supports and promotes a range of clinical audit activity. Have oversight of processes of managing the recommendations from clinical incident analysis, Health and Disability Commissioner, and Coronial investigations. Monitor progress against the health targets and HQSC process markers. 1 G Scally and L.J. Donaldson, Clinical governance and the drive for quality improvement in the new NHS in England. BMJ (4 July 1998): 61-65 2 This is to be reviewed alongside other similar definitions and actioned by the clinical board Whanganui District Health Board 6
ii. Oversee clinical policy and standards and encourage research, development, and innovation Undertake final review and sign-off of all clinical policies and procedures with appropriate delegations to ensure expert oversight. Encourage and support research into evidence-based best practice. Set the culture for clinical research and innovation within Whanganui DHB, including clinical trials. Approve all clinical research applications. Develop policy and processes for clinical projects and projects that require clinical input e.g. annual plan. Oversee continuity of service delivery and supporting system. iii. Guide and support risk management activities across the organisation Provide clinical input into the planning process on clinical risk within Whanganui DHB. Approve annual organisational quality and risk plans. Provide advice and make significant decisions to reduce identified clinical risk across Whanganui DHB. Review, provide advice and make significant decisions regarding serious and sentinel events and incident reports and make improvements where necessary. Ensure the provision of tools to support risk identification across the organisation. iv. Participate in reporting and promotion Ensure there are good processes in place for reporting and promoting clinical activities across the organisation. In order to undertake these responsibilities, the Clinical Board may undertake to delegate some of these tasks to individuals, committees, professional reference groups, or project teams as appropriate. In addition, each of the clinical operational lines within Whanganui DHB has a service improvement committee assuring quality within each service. These committees report to the Clinical Board through the Quality and Clinical Risk Team. The Clinical Board is responsible to the CEO, Whanganui DHB and has the authority under the delegation of the CEO to carry out its roles and responsibilities. A separate schedule is attached outlining the coverage of each of the components of the framework (Appendix 1). 2. Linkages In order for the Clinical Board to fulfil its responsibilities, it will be required to form effective links with the following groups: The Operational Team (OMT), an operational group collectively responsible for managing Whanganui DHB s (WDHB) services, resources, activity and performance, working with clinical leaders to create an environment that enables consistent delivery of effective and integrated client-centred care/services throughout the organisation. The Patient Safety and Quality Directorate, which includes the Quality and Clinical Risk Team and the Risk Advisor, plays an organisation-wide role in promoting and supporting staff in all quality improvement/patient safety endeavours and representing these to the Clinical Board. The director of nursing and patient safety and quality and component services provide support and advice to the Clinical Board on all aspects of patient safety. Whanganui District Health Board 7
Central Region Clinical Board, the six district health boards (DHBs) of the lower north island, known as the Central Region, have a Clinical Board or Safety and Quality Committee made up of senior clinical leaders of each DHB. The board or equivalent body has accountability and responsibility for providing clinical leadership and clinical governance for service planning and direction, and to provide advice/input into regional clinical activities. The aim is to ensure all proposed regional service plan initiatives are evidence-based, safe for patients and staff, and supported by relevant clinicians and consumer groups. The Central Region Safety and Quality Alliance will work to strengthen, align, integrate, and provide direction for local clinical governance systems across the region. 3. Membership/Representation Membership shall include: Nominated/elected representatives of each of the following: Senior Medical Officers (at least one of whom shall be a Clinical Director) (2) Nurse Leaders (2) Community Representative (1) Allied Health Leader (1) Nominated members are expected to have a proxy who can attend when they are unavailable. Standing members: 1. Chief Medical Officer 2. Director of Nursing 3. Manager Patient Safety and Quality 4. Director of Allied Health 5. Midwifery Director 6. Chair, Central Network Clinical Board 7. Director of Māori Health 8. Chair of Regional Health Network Standing members are expected to appoint an alternative who attends any meetings the standing member is unable to. Anyone who is formally in an acting role and holds delegated authority for the role shall attend CB meetings when the period of cover is substantial. All members will have voting rights. A quorum will be 50% of members of whom a majority must be clinicians. Criteria for Membership: Term of appointment for elected members will be two years with a right of two years plus two years renewal of membership, with a maximum of six years. Elected or nominated appointments may be changed by their respective reference groups. 4. Responsibilities of members All clinical members will: Have extensive and current clinical experience. Hold their occupational group registration and have a current practising certificate (where appropriate). Be confirmed by the CEO, Whanganui DHB after consultation with the chief medical officer, director of nursing and patient safety and quality. Understand and be committed to clinical governance. Whanganui District Health Board 8
Preferably, have current or previous involvement in the individual s Professional Body/Association or College where applicable. Have recognised credibility as a clinician in his or her own field. Demonstrate commitment to organisational goals and strategic development. Have dedicated time to participate in the work of this committee. Chair: The chair of the board will be either the chief medical officer, the director of nursing, or the director of allied health. The deputy chair will be the chief medical officer, the director of nursing, or the director of allied health, whomever is not the chair. The chair will liaise with the CEO WDHB with regard to appropriate resources to ensure the functionality of the committee. The chair may call extra meetings outside those scheduled as required to deal with matters that arise of interest to the Clinical Board (CB). (Giving 48 hours prior notice.) Review Terms of Reference at least every two years. 5. Meeting structure and administrative support The schedule for CB meetings will be decided by January for the next 12 months and be distributed to all CB members. Meetings will be monthly with a minimum of 10 meetings held per annum. Meetings will not exceed two hours in duration. The chair has the right to place agenda items into committee as deemed appropriate. Any meeting requiring decision-making that does not meet the requirements of a quorum will be re-scheduled for consideration by the full membership. Administrative Support The Chair will liaise with the CEO, Whanganui DHB to appoint an administrative support person who will: 1. Record, type and distribute minutes to CB members within seven days of meetings and ensure a copy of the previous meeting minutes is placed on a master file. 2. Use a standard template for meeting agenda based on the reporting schedule requirements. 3. Keep accurate records of CB proceedings. 4. Keep a rolling action plan of matters arising from each meeting. 5. Call for agenda items and distribute agenda for upcoming meetings to members at least five days prior to the meeting date. 6. Communicate issues (under the direction of the chairperson) that need to be addressed by the operational management team, and/or the executive management team, within seven working days of meetings. 6. Reporting Committees and groups reporting to the Clinical Board There will be an annual reporting schedule for the named responsible managers/leaders to provide reports to the Clinical Board (see Appendix 1). This will form the basis for monitoring of clinical performance and activity (Appendix 2). Not all the activities listed in the framework represent a committee or a group but rather a function or a mechanism to ensure the Clinical Board is informed of all activity occurring. The Clinical Board will also receive three-monthly reports from Patient Safety and Quality on clinical quality improvement activities. This is inclusive of line activities. Whanganui District Health Board 9
Reports from the Clinical Board The Clinical Board will provide twice-yearly reports to the Hospital Advisory Committee (HAC) and the Risk and Audit Committee (RAC). The Clinical Board will report to the WDHB governing body at their request, or that of the CEO. The CEO will receive the board agenda and meeting minutes. The Chair will meet with the CEO quarterly and will report formally twice-yearly. 7. Review/Amendments The Clinical Board will review the Terms of Reference every two years, and the CEO Whanganui DHB will evaluate annually the performance of the Clinical Board. Whanganui District Health Board 10
Appendix 1: The WDHB structure which supports the Clinical Governance Framework Board of Governors Hauora a Iwi CE Central Region Quality & Safety Alliance Ethics Committee Clinical Board EMT Regional Women s Health Professional Competence & Practice Improveme Clinical Risk & Patient Experience Clinical Service Improvement Support Services, Improvement, Planning & Investment, and Organisational Risk Staff Health and Wellbeing CMO/DON/DAH DON & Manager Patient Safety/ Director Maori Health/ Comms Manager CDs/NMs/AHM/ BMs GM Strategic & Corporate/ GM Business Planning & Support GM HROD Medical Credentialling Incident Medical Services Health Informatics Health & Safety Nursing PDRP Complaints Surgical Services Administration Advisory Group Union Forums Midwifery QLP Infection Women s Health Finance Medical Staff Association Nursing Advisory Group Midwifery Advisory Group Allied Advisory Group Medical Audit PUP & Wound Restraint Falls Clinical Communication Morbidity & Mortality Children s Health Mental Health Older Person s Health Public Health Buildings & Grounds Contracted out services Exceptional Circumstances/New Technologies Capital Investment Product Evaluation Nursing Audit Patient/Family Advisors Service Planning Hospitality Services Patient Information Drug & Therapeutics Director Maori Health Tools, Training, Data Analysis, Project, Quality PERFORMANCE FRAMEWORK Whanganui District Health Board 11
Appendix 2: Schedule of Clinical Board Coverage and Responsibilities Area of responsibility 1. Clinical performance Coverage Certification Accreditation Colleges IANZ Service improvement committees Credentialing 2. Clinical audit Mortality and morbidity reviews 3. Research and development Individual audit Team/departmental audits Clinical trials 4. Risk management Serious and sentinel events Risk matrices Incident reports Annual organisational quality and risk plans Oversee continuity of service delivery and supporting system 5. Reporting and promotion Committees Reference groups Project work Annual workplan Whanganui District Health Board 12