QUALITY & SAFETY COMMITTEE WORKPLAN 2013/14 Introduction The role of the Quality and Safety (Q&S) Committee is to provide: evidence-based and timely advice to the Board to assist it in discharging its functions and meeting its responsibilities with regard to the quality and safety of healthcare; and assurance to the Board in relation to the thb s arrangements for safeguarding and improving the quality and safety of patient-centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales. Therefore, in summary, the role and responsibilities of the Quality and Safety Committee will include:- Overseeing the initial development of the thb s strategies and plans for the development and delivery of high quality and safe services; Considering the implications for quality and safety arising from the development of the thb s corporate strategies and plans or those of its stakeholders and partners; Considering the implications for the thb s quality and safety arrangements from review/investigation reports and actions arising from the work of external regulators; Seeking assurances that governance arrangements are appropriately designed and operating effectively to ensure the provision of high quality, safe healthcare and services across the whole of the thb s activities; Advising the Board on the adoption of a set of key indicators of quality of care against which the thb s performance will be regularly assessed. Programme of Work To fulfil the role of the Quality and Safety Committee effectively, the Committee s Workplan will be designed to provide assurance to the Board that:- the organisation, at all levels, has a citizen-centred approach, putting patients, patient safety and safeguarding above all other considerations; the care planned or provided across the breadth of the organisation s functions is consistently applied, based on sound evidence, clinically effective and meeting agreed standards; the organisation, at all levels, has the right systems and processes in place to deliver, from a patient s perspective efficient, effective, timely and safe services; the workforce is appropriately selected trained, supported and responsive to the needs of the service, ensuring that professional standards and registration/revalidation requirements are maintained; there is an ethos of continual quality improvement and regular methods of updating the workforce in the skills needed to demonstrate quality improvement throughout the organisation; Page 1 of 8
risks are actively identified and robustly managed at all levels of the organisation; there is continuous improvement in the standard of quality and safety across the whole organisation continuously monitored through the Standards for Health Services; recommendations made by internal and external reviewers are considered and acted upon on a timely basis; and lessons are learned from patient safety incidents, complaints and claims. The Board s Strategic Objectives In April 2013, the Board approved its Annual Plan 2012/13. The purpose of which is to clearly articulate the Board s priorities for the financial year and provide the basis for developing a performance management framework which, in turn, gives the Board an open composite view of performance against objectives and provides the basis on which accountabilities for delivery can be defined. Within the Annual Plan 2013/14, the Board has confirmed its vision and ambition as to enable Truly integrated care, centred on the individual by:- Promoting health and wellbeing Ensuring the right access Striving for excellence Involving the people of Powys Making every pound count. The underpinning aims and improvement actions contained within the Annual Plan 2013/14, confirm that the thb has a significant quality and safety agenda to progress across the organisation. The Board has delegated the monitoring and scrutiny of the arrangements for Quality and Safety to the Quality and Safety Committee. In order to inform the development of this work, the Committee held a development session in April 2013 to agree its additional areas of work for the coming year. Additional to the core business requirements of the Committee s Workplan, the Committee agreed that it would give focus to the following strategic objectives during 2013/14:- Vaccinations:- Increase uptake of childhood vaccinations to 95% target through the implementation of the Powys Immunisation Action Plan; Increase uptake of flu vaccination amongst at risk population to 75% and health care workers to 50% through the implementation of the Powys Flu Action Plan Implement year one of three year repatriation project for adult services and Year 2 of the Scheduled Care Repatriation Project for children s services (paediatrics) and maternity services Deliver timely access to scheduled care services, and risk assess services for fragility and ensure business continuity plans in place Influence delivery of service change plans in neighbouring health boards (South Wales Programme; Hywel Dda and Betsi Cadwalladr) to reduce risk of fragile services to Powys residents Implement Year 1 of the Together for Mental Health Strategy, specifically: Test current governance arrangements Develop and implement Powys Five Ways to Wellbeing Evaluate Mental Health Measure and compliance Page 2 of 8
Develop, agree and implement the adult services modelling (including out of hours services and potential for technology in mental health care); Implement key milestones of Suicide Prevention Action plan; Develop, agree and implement a Community Intensive Service solution for children and young people Implement the sustainability and improvement plan for specialist Child and Adolescent Mental Health services Increase transparency of patient experience and health outcomes and patient related quality and safety data at Board level Implement quality assurance framework for receiving, evaluating and taking action where quality triggers or measures highlight potential for substandard care/problems Further develop an internal communications strategy, to systematically gain, record and act on the views of staff Embed the 3 year service and workforce plan that demonstrates the future service model that delivers recurrent financial balance within the resource allocation from Welsh Government The Board In August 2013, the Board will consider its business cycle for 2013/14. In doing this, it will set out its requirement for the involvement of its committees and advisory groups in providing advice and guidance on proposed corporate plans and strategies. Therefore, the Committee s business cycle will need to be flexible to ensure that it includes any additional work as a result of the Board s business cycle. The Audit Committee In July 2013, the Audit Committee held an informal workshop to discuss areas of risk/concern, identified during 2012/13, where further assurance was required by the Board in 2013/14. Discussion was also held regarding the role of the Quality and Safety Committee and it was agreed that there were a number of areas which were relevant and should be included in the Committee s workplan so that the Committee could provide the Audit Committee with the assurances needed, ensuing an integrated way of working between assurance committees of the Board. Areas identified for inclusion in the Quality and Safety Committees Workplan is as follows:- Issues identified in the Annual Governance Statement 2012/13 Concerns Team: capacity issues affecting compliance statistics Care Home Governance: Internal Audit recommendations Recommendations made by Information Commissioner s Office High Rated Risks: Outstanding Audit Recommendations Controlled Drugs: The Health Board should prioritise the resolution of the issue surrounding the administration of controlled drugs not being witnessed by a second member of qualified staff. Medical Devices When a decision has been made regarding which system is going to be the primary system for recording and managing medical devices, maintenance dates should be included and maintained. During this process, a review should be conducted to obtain assurance that all medical devices / equipment are Page 3 of 8
maintained in accordance with their schedule. Records Management Sickness Absence Management (South Locality) The Executive Team has approved the implementation of the 'Casenote' module of MIP. This should be implemented as soon as possible to ensure that a more efficient patient records management system, including the tracking of patient records, recording of movements and recording the number of patient notes held by the organisation, is in place. The Toolkit should be followed for all episodes of staff sickness. Managers required to manage the sickness absence process should be provided with training/refresher training in the use of the Sickness Absence Management Toolkit. Further assurance would be gained by the introduction of periodic management review. The management process should be followed in all appropriate cases i.e. from initial informal interview through to termination where appropriate. Relevant documentation should be held on the personal file. Health & Safety Locality Audit Plans A formal audit plan should be developed to ensure procedures are being adhered to by each locality within the Health Board. Frequency of audit should be determined by the risk areas and arrangements should be drawn for follow up and corrective actions. In light of these additional areas of work, the business cycle has been amended to reflect the need for additional reports to provide assurance to the Audit Committee. Consequently, items marked in red signal that the Committee Chair will be required to issue a report to the Audit Committee following consideration by the Audit Committee. The Audit Committee s Workplan has been updated to reflect that these assurances will be provided from the Quality and Safety Committee throughout the year. Committee Briefings In addition to key areas of work for the Committee, the Committee agreed that it should receive presentations throughout the year to provide further assurance in respect of service areas, care pathways, service improvement and initiatives. s The Board has established two sub-committees of the Quality & Safety Committee:- Mental Health Act sub-committee Information Governance sub-committee Whilst both sub-committees will have individual workplans, the Quality & Safety Committee will take a key role in overseeing the work of the sub-committees, ensuring that assurance is provided in respect of their delegated remits and sub-committee work remains aligned to the organisation s strategic direction. Page 4 of 8
External Reviews Healthcare Inspectorate Wales In August 2012, Healthcare Inspectorate Wales published its Three Year Programme 2012-15 which aims to respond to the key areas of concern facing patients, service users, the public and other key stakeholders (including health service organisations). For 2013/14, HIW will undertake work in the following areas:- Management of care of patients with fractured neck of femur; Food, fluid and nutritional care: are the food, fluid, nutritional and dietary needs of patients being met? ; Eating disorders; Maternity Services; Speech & Language Therapy; Children s Palliative Care Services; Cancer services: referral pathways; Diagnostic services; Disabled children: are disabled children and young people and their carers and families provided with the necessary support to enable them to live an independent and fulfilled life? ; Provision of care and services to people with autism. Wales Audit Office At its meeting in April 2013, the Audit Committee approved the Board s External Audit Plan for 2013. The Plan includes a number of performance audits, however the Quality and Safety Committee will need to ensure that it gives specific focus to the outcomes in respect of the following pieces of work: Structured Assessment (scoped in the context of the Francis ); Community Nursing Workforce; Speciality Focus: Orthopaedics (outstanding from 2012 Audit Plan); and Review of training, teaching and learning (outstanding from 2012 Audit Plan). During 2013/14, the Quality & Safety Committee will ensure that its business cycle is flexible to receive the outcome of these reviews and any response required from the thb is given full consideration. Clinical Audit In April 2013, Welsh Government issued the NHS Wales National Clinical Audit and Outcomes Review Plan: Annual Rolling Programme from 2013/14. The Plan confirms how the findings from the National Clinical Audit and Clinical Outcome Review Programme will be used to measure and drive forward improvements in the quality and safety of healthcare services in Wales. The Plan details the responsibilities of organisations and includes a list of National Clinical Audits and Patient Outcome Reviews which all organisations must participate where they provide the service. The thb will be required to produce an organisational clinical audit programme in response to the National Plan and also include information in respect of any planned local clinical audits for 2013/14. Page 5 of 8
During 2012/13, the Quality & Safety Committee will ensure that its business cycle is flexible to receive the outcome of these audits and any consequential actions required are given full consideration. Internal Audit At its meeting in May 2013, the Audit Committee approved the Board s Internal Audit Plan for 2013/14. The Plan includes a number of internal audits, however the Quality and Safety Committee will need to ensure that it gives specific focus to the outcomes in respect of the following pieces of work:- Annual Quality Statement (Q1); Medicines Management (Q2); and Putting things right: complaints, incidents and redress (Q3). In June 2013, the Audit Committee received three limited assurance rated reports which related to: Data Protection Caldicott Records Management It was agreed that the Quality & Safety Committee would receive assurances against the recommendations made by Internal Audit, via the Information Governance sub- Committee, and report these into the Audit Committee. The Quality and Safety Committee s Business Plan has been amended to reflect this. Executive Director Portfolios All Executive Directors of the thb will have responsibility, as delegated by the Board, for elements of the thb s quality and safety agenda and will therefore have a role in providing the Committee with assurance throughout the year in response to the Committee s core business requirements. To address this, all Directors will be consulted prior to the Quality and Safety Committee agenda setting meeting (held with Committee Chair, Committee Executive Lead and Corporate Governance Manager) to ensure that all relevant information is captured and included in assurance reporting to the Committee. Business Cycle In light of the key areas of work identified for the Committee and the request for identified briefings, a business cycle has been developed to ensure that all areas identified are factored into the Committee s agenda during 2013/14. The Business Cycle will also capture any routine business that the Committee should expect to receive. The Business Cycle will be seen as a dynamic document and updated as and when required, particular in respect of capturing outcomes of external reviews and audits (clinical and non-clinical). Page 6 of 8
AREA OF WORK Committee Briefing/Presentation Improving Health & Wellbeing QUALITY & SAFETY COMMITTEE BUSINESS CYCLE 2013/14 MEETING DATES July 2013 September 2013 November 2013 February 2014 April 2014 South Locality North Locality Mental Health & LD Mid Locality Women and Directorate Children s Directorate Primary Care Action Primary Care Action Public Health Update Vaccinations Plan Plan (incl vaccinations) Primary Care Action Vaccinations Public Health Update Plan (inc vaccinations) Ensuring the Right access Service Change Plans (neighbouring Health Boards) Unscheduled Care Unscheduled Care Access to scheduled care CAMHS Mental Health Services (including progress against WAO MH Services Review) Service Change Plans (neighbouring Health Boards) Update on Unscheduled Care Action Plan Access to scheduled care Mental Health Services CAMHS Striving for Excellence ing 1000 Lives Plus Programme Clinical Audit Plan (Local & National) Clinical Audit Plan (Local & National) ing Standards for Health Services Quality Assurance Framework Workforce Plan 2013/14 ing 1000 Lives Plus Programme Annual Concerns Clinical Audit Plan: Progress Workforce Plan 2013/14 Care Home Governance Quality Assurance Framework Estates Compliance ing Standards for Health Services Care Home Governance Update on External Inspections Clinical Audit Plan: Progress Communication Strategy (staff engagement) Francis Engagement Events 1000 Lives Plus Programme ing Putting Things Right 1000 Lives Plus Programme Quality Assurance Framework Workforce Plan 2013/14 Clinical Audit Plan: Progress Health & Safety Audit Plan (including localities) Estates Compliance Page 7 of 8
Governance & Assurance Draft Annual Quality Statement Committee Annual 2012/13 Committee Workplan 2013/14 s: MHA IG Final Annual Quality Statement Committee Induction Process Structure of relevant committees and groups s MHA IG Committee Induction Process Structure of relevant committees and groups s MHA (including presentation on MH Capacity Act) IG (including progress on IG Follow Up Reviews, ICO Recommendations & High rated Audit Recommendation) Update on High rated Audit Recommendations: Controlled drugs Medical Devices Sickness Absence Review of Committee Terms of Reference Committee selfassessment s MHA IG Committee Annual 2013/14 Committee Workplan 2014/15 s MHA IG Page 8 of 8