PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE Page 1
DOCUMENT CONTROL SHEET Name of Document: Patient Safety and Quality Committee Terms of Reference Version: 5 File Location / Document Name: Policy Repository Patient Safety and Quality Committee Terms of Reference Date Of This Version: 23/11/2015 Produced By: Reviewed By: Synopsis And Outcomes Of Equality and Diversity Impact Assessment: Ratified By (Committee): Director Quality and Safety Patient Safety & Quality Committee members No adverse impact identified The Governing Body Date Ratified: March 2013 Distribute To: Members of the Patient Safety and Quality Committee Date Due For Review: November 2016 Enquiries To: Director Quality and Safety; Patient Safety and Quality Committee Chair Revision History Revision Date Summary of changes Author(s) Version Number 18/02/2013 To include Sharepoint feedback Amend 19 to include successor organisations Section 5 other representatives from Provider organisations to be co-opted as required Director Quality and Safety 2 20/01/2014 - To add secondary care doctor/governing Body representation to the membership. Director Quality and Safety 3 - Remove the specific reference to the safeguarding representatives. 26/08/2014 To review and amend membership to take into account the Quality Team coming in-house to the CCG and no longer referring to the NEL CSU. To amend references to read transformation Programme. To confirm the title of the Cluster Q&S meetings. Director Quality and Safety 4 Page 2
23/11/2015 1.4 to include an additional bullet point clarifying that the PS&Q Committee will monitor outcomes of all CQC inspections. 2.2 to add a point around engaging with patients and carers on strategic issues. 5.0 Add another Lay Member to the membership list. Director of Commissioning & Quality 5 Page 3
PATIENT SAFETY AND CLINICAL COMMITTEE TERMS OF REFERENCE 1 PURPOSE 1.1 To provide a whole-system forum to support the commissioning of health services by focussing systematically on improving patient safety, experience and quality, with quality as the organising principle. Service providers will publish information on these dimensions in the form of Quality Accounts ( High Quality Care for All refers). 1.2 To work in partnership throughout the health and social care system in Great Yarmouth and Waveney to implement systems which respond to the views and experiences of patients and improve patient experience of services; to use Local Commissioning for Quality and Innovation (CQUIN) schemes to put patient and carer experience at the centre of transformation programme. 1.3 To value carers as expert care-partners and recognise that their health and wellbeing can be affected by their caring role (National Carers Strategy and Carers at the Heart of 21 st Century Families and Communities refer). 1.4 To support the Governing body of Great Yarmouth and Waveney CCG in overseeing High Quality Care for All and realising its ambition for the people of Great Yarmouth & Waveney by: bringing greater clarity to quality and planned quality improvements; measuring quality; Monitoring outcomes of CQC Inspections; publishing performance about quality; recognising and rewarding quality; raising standards; safeguarding quality; and staying ahead by supporting and promoting innovation. reviewing feedback from the Sharepoint meetings 2 OBJECTIVES 2.1 Patient Safety and Quality 1. To develop the strategic vision for patient safety and clinical quality. 2. To test the constituent elements of each Programme Board s work against the quality agenda, ensuring that patient and carer experience sits at the centre of transformation programme. 3. To review the health system s compliance with national standards including Care Quality Commission standards; National Service Frameworks; and NICE guidance by exception. 4. To inform Governing Body thinking and action on the role of Quality, Innovation, Productivity and Prevention (QIPP) in driving and embedding improvement opportunities and initiatives. Page 4
5. To commission assessment of services where clinical practice falls below best practice. 6. To ensure that Commissioning, Quality and Innovation (CQUIN) proposals are appropriate, challenging and lead to significant improvement in quality of services. 7. To ensure that all commissioned services have a robust clinical audit programme in place and that results are reviewed and acted upon as necessary. 2.2 Patient and Carer Experience 8. To ensure that priority is given to improving patient experience in line with local, regional and national priorities and measurements. 9. To ensure that continuous and meaningful engagement with carers enables them to shape services as co-producers. 10. To ensure all service providers consider seldom-heard groups in their patient and carer experience work to ensure inclusion and reduce health inequalities; and to monitor service providers action plans arising. 11. To develop processes for reviewing and acting upon Never Events (NEs) and Serious Incidents Requiring Reporting (SIs). 12. To develop processes for reviewing and acting upon Staff and Patient Survey outcomes. 13. To engage with patients and carers on strategic issues. 2.3 Governance 14. To embed systems and processes for safeguarding Patient Safety & Quality in commissioning practice. 15. To agree and ensure that patient safety quality indicators are included in all provider contracts, and monitored by attendance a t the monthly contract and quality meetings. 16. To manage systems effectively and work in partnership with service providers to ensure contract compliance and continuous improvements in quality and outcomes. 17. To monitor risk as part of routine reporting, providing challenge where required and setting improvement targets as necessary; to incorporate areas of potential risk in Great Yarmouth and Waveney CCG s Risk Register and Board Assurance Framework as necessary; and ensure that action is taken to mitigate or eliminate such risks. 18. To review information pertaining to Never Events (NEs), Serious Incidents (SIs), significant clinical incidents, complaints trends and Serious Case Reviews, ensuring that corrective and preventative action is taken and that lessons learned are disseminated throughout the local Health System, working with the Quality leads from the four Norfolk CCGs. 19. Quality meetings with the individual Providers are in place, with the Quality and Safety team in attendance at all meetings. These meetings will feed into this Committee and if any issues are identified then relevant representation would be required to attend a Committee meeting to discuss further. Page 5
20. The Director of Quality and Safety (and/or the Heads of Quality and Safety) to attend the monthly Quality Network Meeting and the quarterly Quality Strategic Alliance to share learning with the other Norfolk CCGs. 3 ACCOUNTABILITY The Committee is accountable to the Governing Body. Minutes of its meetings, together with any supporting reports, will be submitted to the Governing Body on a monthly basis. The Committee s minutes will also be presented regularly to the Audit Committee. 4 FREQUENCY OF MEETINGS Meetings of the Committee will be held on a monthly basis and scheduled in line with Governing Body meetings for reporting purposes. 5 MEMBERSHIP Lay member of the Governing Body (Chair) Lay member of the Governing Body Secondary care clinician/governing Body representative (Deputy Chair) Director of Commissioning & Quality, Great Yarmouth and Waveney CCG (Deputy Chair) Heads of Quality and Safety, Great Yarmouth and Waveney CCG Other members of the Quality & Safety Team, Great Yarmouth and Waveney CCG, as required and delegated by the Director Commissioning & Quality Representative from; Public Health lead for HCAI Other representatives from provider organisations to be co-opted as required. 6 QUORUM A quorum will comprise 3 members including either the chair or one of the nominated deputy chairs, and two other representatives from a clinical field. 7 REVIEW These terms of reference will be reviewed on an annual basis. Page 6