approach to governance · 2015-11-14 · organisation evolve i.e. new director appointments;...

APPROACH TO CLINICAL

GOVERNANCE

CLINICAL GOVERNANCE TASK & FINISH GROUP October 2009 (Final Draft)

INDEX Page

1. Purpose 3

2. Scope of the paper 3

3. Clinical Governance in context 3-5

4. Key deliverables 5

5. All Wales Save 1000 Lives Campaign 6

6. Reporting Arrangements 6

7. Key policies 7

8. Conclusion 7

APPENDICES Appendix 1 Draft Terms of Reference for the Quality,

Patient Safety and Public Health Committee Appendix 2 Former Trust and LHBs Sub-Committee

arrangements Appendix 2a Proposed Sub-Committee arrangements Appendix 2b Proposed ‘Draft’ agenda for the inaugural

Quality, Patient Safety and Public Health Committee meeting

Appendix 3 Clinical Governance related Leads Appendix 4 Key Policies

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1. PURPOSE This paper has been prepared by the Clinical Governance Task & Finish Group for consideration by the Governance Work Stream outlining the recommended approach to Clinical Governance within the Cwm Taf Local Health Board. 2. SCOPE OF THE PAPER This paper is in line with the Terms of Reference and end product checklist of the Clinical Governance Task & Finish Group agreed by the Governance Work Stream and Project Board. However, it is recognised that as arrangements for the new organisation evolve i.e. new Director appointments; clarity around guidance on Stakeholder and Professional Reference group remits; the establishment of the Specialist Health Services Commissioning Committee (SHSCC) and its related functions, the proposed Clinical Governance arrangements may change as a consequence. 3. CLINICAL GOVERNANCE IN CONTEXT Clinical Governance is one of a number of key components which inform the Governance arrangements of an NHS Organisation. Every day more than a million patients are treated safely and successfully in the NHS. In Cwm Taf LHB this translates to many thousands of patients each day. However, in a complex healthcare system, things can and do go wrong, no matter how dedicated and professional the staff. Clinical Governance is the infrastructure in which NHS organisations ensure that patients are safe; risks are managed; care is effective; improved quality in service is continuous; staff are competent and fit to practice and experienced is learned.

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In this infrastructure, Clinical Governance can be defined as: “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” (Putting Patients First, 1998) Within Cwm Taf, the patient, the quality of their care and their safety must always remain at the centre of all that the Local Health Board does. These perspectives, supported by the Healthcare Standards for Wales, should be used as a constant reference point to ensure relevance, substance and deliverability of sound Clinical Governance arrangements. The 7 new values underpinning the establishment of the new NHS Structure in Wales are;

• Putting Patients and Patient Safety above all things; • Maintaining consistently high standards of care; • All services being given equal prominence; • Open and transparent governance; • Compliance with the highest standard of probity; • Strong commitment to partnership working; and • Valuing staff.

It is important if Clinical Governance is to flourish and Patient care and Patient Safety are put above all things, that the service functions efficiently and effectively. The effective use of resources will assist in meeting these underpinning values. Cwm Taf LHB has focused carefully on developing the Clinical Governance arrangements across the new organisation. These arrangements have been fully informed by the strengths of the three former organisations.

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NHS Reorganisation has provided the opportunity for Clinical Governance systems and processes to be reviewed. The development of these arrangements will need to be reviewed in light of the maturing organisation. The LHBs Divisional structure supported by the Patient Care and Safety Directorate will introduce and implement robust systems and processes to support good clinical governance arrangements across the health community and provide support to Independent Contractor Professions aligned to the Healthcare Standards for Wales. The Healthcare Standards for Wales (2005) will need to be integral to any arrangements developed for the Local Health Board. The patient, the quality of their care and their safety must always remain at the centre of all that the Health Board does. These perspectives should be used as a constant reference point to ensure relevance, substance and deliverability of robust Clinical Governance arrangements across Primary and Secondary Care. 4. KEY DELIVERABLES In order to achieve the above it will be necessary for the Clinical Governance Task & Finish Group to provide the Governance Work Stream and ultimately the Project Board with the following:

• Identification of the key aspects of Clinical Governance; • A proposed Clinical Governance Structure which also

incorporates Independent Contractors; • The Reporting arrangements and individual responsibilities

within these required to ensure the quality and safety of patient care throughout the Local Health Board;

• The development of Organisational Policies, Standards and Guidance which will ensure a consistent approach to the implementation of the key elements of Clinical Governance;

• Identification of key Clinical Lead appointments required for Cwm Taf LHB;

• Demonstrate best use of resources.

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“Governing the NHS – A Guide for NHS Boards” recommends a control framework which consists of three overlapping systems; Controls Assurance, Clinical Governance and Risk Management. Clinical Governance is a comprehensive system of measures controlled by the Board which measures the quality and effectiveness, including cost effectiveness of clinical services and procedures. Specifically it is the Board’s responsibility to ensure appropriate control systems are in place and that quality and safety of patient care is not pushed from the agenda by immediate operational issues. 5. SAVE 1000 LIVES PATIENT SAFETY CAMPAIGN The Trust and both Local Health Boards have been actively involved in the All Wales ‘Save 1000 Lives’ Campaign. The Trust and LHBs have had discussions around aligning work streams where appropriate and this will include;

• Leadership for Quality • Healthcare Associated Infections • Medicine’s Management

LHB arrangements for informing the direction, implementation and monitoring of the campaign will evolve aligned to the establishment of Cwm Taf LHB. 6. REPORTING ARRANGEMENTS It will be necessary for Cwm Taf Health Board to delegate some of its powers to formally constituted committees. These committees will have a remit and decision making powers defined in this section and will report back to the Health Board at agreed intervals. The Committees may set up Sub-Committees and may in turn delegate powers to them.

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Committees consume a considerable amount of time. In developing the proposals in this paper the reporting structure has been kept to a minimum with the overriding principle that they need to add value. Views have been taken from Executive Directors of the Trust and both Local Health Boards and has also been debated at the Clinical Governance Task and Finish Group. It is recommended therefore that there is a need to establish a Quality, Patient Safety and Public Health Committee. Attached as Appendix 1 and 2 to this document are the draft terms of reference for the Committee. Also attached are the existing structures of the Trust and LHB Clinical Governance arrangements. Appendix 2a outlines a proposed ‘draft’ Committee sub – structure which again will evolve as clarity around the establishment of the new organisation unfolds. Appendix 2b provides a ‘draft’ outline of the proposed Agenda for the inaugural Quality, Patient Safety and Public Health Committee of the Local Health Board. Reporting of Screening Panel and Reference Panel Processes Currently, Merthyr Tydfil LHB and RCT tLHB are required to have in place a Screening Panel Process and Reference Panel to consider performance issues relating to Independent Contractors as detailed in the All Wales operational policies on the management of poor performance by contractors (Doctors/ Dentists) on the Wales Performers List. From the 1st October 2009, these responsibilities will transfer to the new Cwm Taf LHB. Within Cwm Taf LHB it is proposed that these responsibilities will continue within the Medical Director portfolio and is serviced through the Clinical Governance arrangements working closely with the Director of Primary, Community and Mental Health Services and where appropriate the Director of Workforce and Organisational Development.

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It is further proposed that the reporting arrangements for the Screening Process Panel and Reference Panel are reported by the Medical Director through the ‘in committee’ session of the LHB Board. 7. KEY POLICIES There is a requirement that Clinical Policies required for Cwm Taf LHB need to be reviewed and considered in light of the development of the new Organisation. In the absence of new Policies, it is essential that a Policy Statement outlining the arrangements relating to the former organisations Policies and how they will be applied within the new LHB. To inform the opinion as to whether there were any essential Policies required prior to 1st October 2009, arrangements were reviewed by the Clinical Governance Task & Finish Group. Default positions for each category of policy are being agreed. 8. CLINICAL LEAD/CHAMPIONS It will be necessary for Cwm Taf Local Health Board to ensure that where there are requirements either through statute or from WHCs / Ministerial letters, to ensure Director Leads/Champions are in place, that these are factored into the arrangements for the new Organisation. 9. CONCLUSION This paper allows the Governance Work Stream to ensure that all the key aspects required for good and effective Clinical governance will be in place for the Cwm Taf Local Health Board when it becomes operational on 1st October 2009. It is recognised that further discussions are required with members of the new Executive team. In addition, interpretation of the guidance in relation to new established groupings will influence any final arrangements. It is also recognised that the processes relating to Clinical Governance will continue to evolve.

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APPENDIX 1

TERMS OF REFERENCE

QUALITY, PATIENT SAFETY AND

PUBLIC HEALTH COMMITTEE

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INTRODUCTION

The LHB’s standing orders provide that “The Board may and, where directed by the Assembly Government must, appoint Committees of the LHB either to undertake specific functions on the Board’s behalf or to provide advice and assurance to the Board in the exercise of its functions. The Board’s commitment to openness and transparency in the conduct of all its business extends equally to the work carried out on its behalf by committees”. In line with standing orders (and the LHB scheme of delegation), the Board shall nominate annually a committee to be known as the Quality, Patient Safety and Public Health Committee. The detailed terms of reference and operating arrangements set by the Board in respect of this committee are set out below. PURPOSE The purpose of the Quality, Patient Safety and Public Health Committee “the 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 LHB’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.

DELEGATED POWERS AND AUTHORITY The Committee will, in respect of its provision of advice to the Board:

• oversee the initial development of the LHB’s strategies and plans for the development and delivery of quality, patient safety and public health, consistent with the Board’s overall strategic direction and any requirements and standards set for NHS bodies in Wales;

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• consider the implications for quality, patient safety and public health arising from the development of the LHB’s corporate strategies and plans or those of its stakeholders and partners

• consider the implications for the LHB’s quality, patient safety

and public health arrangements following publication of review reports and recommended actions arising from the work of external reviewers.

The Committee will, in respect of its assurance role, seek assurances that clinical governance, (including clinical risk management) arrangements are appropriately designed and operating effectively to ensure the provision of high quality, safe healthcare across the whole of the LHB’s activities. To achieve this, the Committee’s programme of work will be designed to ensure that, in relation to all aspects of quality, public health and patient safety:

• there is clear, consistent strategic direction, strong leadership and transparent lines of accountability;

• the organisation, at all levels (division/directorate/clinical

team) has a citizen centred approach, putting patients, patient safety and safeguarding above all other considerations;

• the provision of care across the organisation

(division/directorate/clinical team) is consistently applied, based on sound evidence, clinically effective and meeting agreed standards;

• the organisation, at all levels (division/directorate/clinical

team) has the right systems and processes in place to deliver, from a patients perspective - efficient, effective, timely and safe services;

• the workforce is appropriately selected, trained and

responsive to the needs of the service, ensuring that professional standards and registration/revalidation requirements are maintained;

• there is good team working, collaboration and partnership

working to provide the best possible outcomes for its citizens;

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• risks are actively identified and robustly managed at all levels of the organisation;

• decisions are based upon valid, accurate, complete and timely

data and information;

• there is continuous improvement in the standard of quality and patient safety across the whole organisation – evidenced through the Healthcare Standards for Wales;

• all reasonable steps are taken to prevent, detect and rectify

irregularities or deficiencies in the quality and safety of care provided, and in particular that: Sources of internal assurance are reliable, eg. internal

audit and clinical audit teams have the capacity and capability to deliver;

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 Committee will advise the Board on the adoption of a set of key indicators of quality of care, against which the LHBs performance will be regularly assessed. These will include the following; Clinical Governance

• Oversee and monitor the development of the Clinical Governance Strategy for Cwm Taf LHB;

• Monitor the co-ordination and implementation of the Healthcare standards for Wales within the LHB;

• Agree the Clinical Governance Annual Report and the Annual Healthcare Standards Improvement Plan prior to endorsement by the Local Health Board and monitor progress with implementation of the Plan;

• Receive, consider and provide reports as appropriate from / to other standing Committees/Sub Committees;

• Support the development of Clinical Governance arrangements for Independent Contractor Professions.


Patient Experience

• Review reporting trends relating to patient safety incidents with particular emphasis on ensuring that lessons learnt and all actions necessary to reduce the likelihood of further incidents have been identified and taken;

• Receive and review progress reports relating to the requirements identified for patient safety and clinical governance activity;

• Review reporting trends relating to clinical negligence claims with particular emphasis on ensuring that lessons learnt and all actions necessary to reduce the likelihood of further claims have been identified and taken;

• Receive and review reports on the progress relating to the implementation of the Patient Experience Strategy;

• Receive reports on the systematic evaluation of the patient experience.

Policies and Procedures

• Authorise appropriate Clinical Policies and related Procedures on behalf of the Local Health Board;

Complaints and Compliments

• Receive quarterly reports on complaints and the reporting trends relating to the progress and outcome of all formal complaints with particular emphasis on ensuring that lessons learnt and all actions necessary to reduce the likelihood of further complaints have been identified and taken;

• Monitor the investigation of complaints to ensure quality standards are met;

• Ensure an effective reporting system to the Local Health Board;

• Receive the Annual Complaints Report including the analysis of compliments received during the year.

Clinical Audit & Effectiveness

• Receive reports on the progress and lessons learnt from clinical audit & effectiveness which will include updates on national standards implementation e.g. NSF’s, evidence based practices.

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Clinical Risk

• Monitor the arrangements in place to assess, control and reduce clinical risk across the Local Health Board.

Research & Development

• Receive reports on the progress on Research & Development activity within the organisation focussing on the outcomes for patients and compliance with Research Risk Governance arrangements.

Authority The Committee is authorised by the Board to investigate or have investigated any activity within its terms of reference. In doing so, the Committee shall have the right to inspect any books, records or documents of the LHB. It may seek any relevant information from any employee and all employees are directed to cooperate with any reasonable request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers it necessary, in accordance with the Boards procurement, budgetary and other requirements. Sub Committees The Committee may, subject to the approval of the LHB Board, establish sub committees or task and finish groups to carry out on its behalf specific aspects of Committee business. The following sub committees/task and finish groups are outlined in Appendix 2A. MEMBERSHIP Four (4) Non Officer Members to include the Chair of the Audit Committee and the Vice Chair of the Health Board. One Non Officer Member shall be designated as Chair of the Committee and another as Vice Chair.

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In Attendance: - Chief Executive Medical Director Nurse Director Director of Primary, Community and Mental Health Services Director of Therapies and Health Science Director of Public Health Director of Finance Nominated Trade Union Representative Clinical Lead for Clinical Audit & Effectiveness Clinical Lead for Research & Development Assistant Director of Patient Care & Safety Divisional Representatives (x4) Community Health Council Representative Welsh Assembly Government Clinical Governance Support &

Development Unit (CGSDU) Representative Stakeholder Reference Group Representative Professional Forum Representative

Secretary As determined by the Board Secretary By invitation The Committee Chair may extend invitations to

others to attend committee meetings as required. Member Appointments The membership of the Committee shall be determined by the Board, based on the recommendation of the LHB Chair, and subject to any specific requirements or directions made by the Assembly Government. Appointed members shall hold office for a period of one year, during which time a member may resign or be removed by the Board. Committee members may be reappointed up to a maximum period of three consecutive years. Support to Committee Members The Board Secretary, on behalf of the Committee Chair, shall:

Arrange the provision of advice and support to committee members on any aspect related to the conduct of their role; and

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Co-ordinate the provision of a programme of organisational development for committee members.

COMMITTEE MEETINGS Quorum At least four members must be present to ensure the quorum of the Committee. This must include at least two independent members. Frequency of Meetings Meetings shall be held no less than bi-monthly, and otherwise as the Chair of the Committee deems necessary – consistent with the LHB’s Annual plan of Board Business. REPORTING AND ASSURANCE ARRANGEMENTS The Committee Chair shall:

report formally, regularly and on a timely basis to the Board on the Committee’s activities. This includes verbal updates on activity, the submission of committee minutes and written reports, as well as the presentation of an Annual report;

bring to the Board’s specific attention any significant matters

under consideration by the Committee;

ensure appropriate escalation arrangements are in place to alert the LHB Chair, Chief Executive or Chairs of other relevant committees of any urgent/critical matters that may affect the operation and/or reputation of the LHB.

The Board Secretary, on behalf of the Board, shall oversee a process of regular and rigorous self assessment and evaluation of the Committee’s performance and operation including that of any sub committees established.

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RELATIONSHIP WITH THE BOARD AND ITS COMMITTEES/ GROUPS Although the Board has delegated authority to the Committee for the exercise of certain functions as set out within these terms of reference, it retains overall responsibility and accountability for ensuring the quality and safety of healthcare for its citizens. The Committee, through the Committee Chair and members, shall maximise cohesion and integration across all aspects of governance and assurance through the:

joint planning and co-ordination of Board and Committee business; and

sharing of information

The Committee shall embed the LHB corporate standards, priorities and requirements, e.g., equality and human rights through the conduct of its business. APPLICABILITY OF STANDING ORDERS TO COMMITTEE BUSINESS

The requirements for the conduct of business as set out in the LHB Standing Orders are equally applicable to the operation of the Committee, except in the following areas :

Quorum REVIEW These Terms of Reference shall be reviewed annually by the Committee with reference to the Board.

September 2009

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Current Cwm Taf Trust Arrangements Cwm Taf Trust Arrangements Appendix 2

TRUST BOARD

Clinical Governance Committee

Divisional Integrated Governance Groups

Medicines Management Committee

Research & Development Committee

Clinical Audit & Effectiveness Committee

NICE & Medicines Expenditure Committee

Postgraduate Committee

Undergraduate Committee

Blood Transfusion Committee

Resuscitation Committee

Child Protection Committee

Vulnerable Adults / Domestic Abuse Committee

Infection Prevention & Control Committee

Health Records Committee

Catering & Nutrition Group

Housekeeping Group

Organ Donation Committee

Decontamination Group

Thrombosis Committee


Current Merthyr & RCT tLHB Arrangements Appendix 2

Clinical Governance Committee x 2 RCT / Merthyr Tydfil

Clinical& Risk Governance Operational Group

Screening Process Panel X 1

Clinical Audit & Effectiveness Group

Complaints & Compliments Working Group

Health & Safety Group

LHB BOARD X 2

Joint Trust & LHB Prescribing Advisory Group

Joint Trust & LHB Pharmacy Development Group

1,000 Lives Infection Control Working Group

MERTHYR TYDFIL & RCT LHB JOINT CLINICAL GOVERNANCE STRUCTURE

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Proposed Cwm Taf LHB Arrangements Appendix 2a

QUALITY, PATIENT SAFETY & PUBLIC HEALTH COMMITTEE

Medicines Management Committee

Research & Development Committee

Clinical Audit & Effectiveness Committee

NICE & Medicines Expenditure Committee

Postgraduate Committee

Undergraduate Committee

Blood Transfusion Committee

Resuscitation Committee

Local Safeguarding Children Committee

Vulnerable Adults / Domestic Abuse Committee

Infection Prevention & Control Committee

Health Records Committee

Catering & Nutrition Group

Housekeeping Group

Screening Panel Process / Reference Panel Process for Independent Contractors

Point of Care Testing Committee

Divisional Integrated Governance Groups

Health Board Operational Group

Complaints Panel

Claims Panel

Organ Donation Committee

Decontamination Group

Thrombosis Committee

LOCAL HEALTH BOARD

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Appendix 2b CWM TAF LOCAL HEALTH BOARD

QUALITY, PATIENT SAFETY & PUBLIC HEALTH COMMITTEE

A meeting of the Quality, Patient Safety & Public Health Committee will be held on …………. {Insert Name} CHAIR, QUALITY, PATIENT SAFETY AND PUBLIC HEALTH COMMITTEE

AGENDA Attachment

PRELIMINARY MATTERS

1. Welcome and Introductions

Verbal

2. Apologies for Absence

Verbal

3. Declarations of Interest

Verbal

4. Consider, discuss and adopt Terms of Reference for the Quality, Patient Safety and Public Health Committee

1

5. Quality, Patient Safety and Public Health Committee, Proposed Sub Committees and working groups

2

ITEMS FOR APPROVAL

6. To receive and consider the Clinical Governance Legacy Reports from the former Organizations

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7. To receive consider and approve the Cwm Taf LHB Annual Healthcare Standard Improvement Plan (HCSIP) 2009-2010

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8. To receive and consider the Healthcare Inspectorate Wales (HIW) work programme for 2009/2010

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ITEMS FOR APPROVAL

9. To receive an update on Complaints, Claims and Incident Reporting for quarter 2.

6

ITEMS TO NOTE

10.

POLICIES FOR APPROVAL

11. 12. OTHER MATTERS

13. Any other urgent business

Verbal

14. To agree dates for future meetings

Verbal


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Appendix 3

CLINICAL GOVERNACE RELATED LEADS REQUIRED FOR

CWM TAF LOCAL HEALTH BOARD Function Type

1. Clinical Risk Advisor 2. Domestic Abuse Advisor 3. Environmental Advisor 4. Information Governance Advisor 5. Major Incident Advisor 6. Midwifery - Head of

Midwifery Advisor and Professional Lead

7. Protection of Vulnerable Adults

Advisor

8. Resuscitation Clinical Lead 9. Medicines Management Advisor / Compliance with

legislation 10. Patient and Public

Involvement including Patient Support Service

Champion and Lead Director

11. Children Champion and Lead Director 12. Mental Health Act

Commissioners Non Executive Director Lead

13. Named Doctor, Named Nurse and Named Midwife for Child Protection

Compliance with legislation

14. Pharmacy - registered pharmacies have one superintendent pharmacist

Compliance with legislation

15. Radiation Protection Compliance with legislation 16. Blood Transfusion Laboratory

Manager Compliance with legislation

17. Complaints manager Nominated individual for the LHB

18. Mental Capacity Act Lead Clinician 19. Mental Health Act Lead Clinician 20. Cancer Lead Lead Clinician


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CLINICAL GOVERNACE RELATED LEADS REQUIRED FOR CWM TAF LOCAL HEALTH BOARD

Function Type 21. Cardiac Lead Lead Clinician 22. Clinical Audit and

Effectiveness Lead Clinician

23. Ethics Lead Clinician 24. Organ Donation Lead Clinician / Non

Executive Champion 25. Human Tissue Act –

Designated individual and licence for LHB

Lead Clinician

26. Lead Supervisor Of Midwives Lead Clinician 27. Postgraduate medical

education Lead Clinician

28. Research and development Lead Clinician 29. Undergraduate medical

education Lead Clinician

30. Infection Control Lead Clinician/ link to outbreak team NPHS

31. Caldicott Guardian Lead Director Compliance with legislation

32. Child Protection Lead Director Compliance with legislation

33. Emergency Care Lead Lead Director


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Appendix 4

ESSENTIAL POLICIES AND PROCEDURES

CLINICAL GOVERNANCE TASK AND FINISH GROUP

NO ESSENTIAL POLICIES IDENTIFIED THAT ARE

REQUIRED BY 1ST OCTOBER 2009.

approach to governance · 2015-11-14 · organisation evolve i.e. new director appointments;...

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