BUPA UK CLINICAL GOVERNANCE ASSURANCE POLICY. bupa.com

Transcription

1 BUPA UK CLINICAL GOVERNANCE ASSURANCE POLICY bupa.com Date November 2016

2 Document Details Table of Amendments Document New Issue New Issue Description of Change Authorisation Number Number Date Version /11/2014 Inaugural Director of Clinical Governance Version /09/2015 Background updated to reflect current role of the team. Bupa UK Medical Director First line clinical quality assurance definitions process changed. Methodology changed to reflect process in place. Timings changed on generating and approving report Removed section of Audit Logistics Removed section of Process Flowchart updated to reflect methodology Amendment of RAYG rating to align with Centre Medical model Attachment of appendix 1 Version /04/2016 Policy renamed from Second Line Clinical Quality Assurance Programme to Clinical Governance Assurance Policy 3 lines of defence redefined Second line of defence reviews outlined Director of Clinical Governance Appendix 1 removed Version /11/2016 Feedback and comment Angela Odell from business CG leads Nick Price Version /11/2015 Final Review and approval Clinical and Information Risk Committee Members 2 Report Date November 2016

3 Contents 1 Introduction 4 2 Scope 5 3 Conducting a Clinical Governance Assurance Review 5 4 Methodology 6 5 Reports/ Action Plans/ Review 8 Introduction 3 Policy Date November 2016

4 The concept of assurance includes the assessment or evaluation of the quality of service; identification of problems or shortcomings in the delivery of service; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. The Clinical Governance Assurance Policy aims to provide Bupa UK and the Assurance Risk and Compliance Committee (ARCC) with the evidence that all businesses are operating effectively, achieving desired outcomes, delivering on its strategic objectives through effective risk management and is in accordance with all statutory and regulatory requirements. The Clinical Governance Assurance Policy provides a structure and process that enables the businesses to focus on their key risks, examine the controls in place to mitigate and reduce these risks from crystallising and present assurance to ARCC on the effectiveness of these controls. The Policy will deliver this assurance through: Reviewing systems, processes and resources which are operating both at an operational and first line level, ensuring they are being delivered in a safe and effective manner. Implementing a process for reporting key risks and information to the ARC Committee. The principles by which the UK Clinical Governance Team aims to deliver this Policy is by: Putting the customer, member, resident and patient first by focusing on their safety, needs and experiences, ensuring that the business delivers a high quality service. Working with the clinical governance/quality leads in the businesses to understand roles and responsibilities, ensuring that these fit with the requirements outlined in the relevant Enterprise Policies. Work in partnership with the businesses to deliver improved clinical governance systems. Understanding the business and clinical risks and work to achieve improved outcomes and ensure compliance with the regulators. Create and/or nurture a continuous learning and improving culture across all businesses. Achieve value for money, ensuring that resources are efficient, effective and deliver high quality. To guide, assist, monitor activities and improvements across all businesses. Conduct clinical governance assurance reviews in all the businesses on an annual basis. Findings will be reported up through the UK Clinical & Information Risk Committee (CIRC) to ARCC. This process removes the necessity for any other second line clinical assurance activity from centre teams and other Bupa UK teams. Scope 4 Policy Date November 2016

5 This policy applies to all Bupa UK businesses. The UK Clinical Governance Team will deliver assurance to the ARCC and support to the businesses (but not limited to) in the following ways: 1. Undertake clinical governance and risk reviews 2. In businesses where it is required undertake mock CQC reviews in areas where inspection dates have been provided 3. Undertake specific risk reviews in areas where risks have been identified through risk registers, adverse incidents and complaints or findings identified by other businesses or departments 4. Pull best practice together from across the business units 5. Ensure compliance to appropriate enterprise policies through monitoring KPI and returns from business units Conducting a Clinical Governance Assurance Review (1, 2 and 3 above) First Line Clinical Governance Assurance Review Each business in Bupa is considered the first line of defense, as they are responsible for the services and processes that create risks. Therefore, they must accept the ultimate responsibility to own and manage the risks their businesses create, as well as establish the proper tone for managing these risks consistent with the tone at a more senior level. As the principal owners of risk, these businesses set objectives, establish risk responses, train personnel and reinforce risk response strategies. They implement and maintain effective internal control procedures on a dayto-day basis and are best positioned to integrate risk management capabilities with the activities that create the risks. Each business will provide a monthly report of their clinical governance reviews complete with proposed action plans and timeframes for implementation of actions to the UK Clinical Governance Team. The UK Clinical Governance Team will track and monitor the implementation of these actions on a monthly basis and will form part of their clinical governance assurance reviews. Second Line Clinical Governance Review Independent clinical governance, risk management and compliance functions are the second line of defense in Bupa, as they provide an independent, authoritative voice to ensure that an enterprise wide process exists for managing risk, risk owners are meeting expectations in accordance with that process, risks are measured appropriately, risk limits are respected and adhered to and risk reporting and escalation protocols are working as intended. Second line clinical governance assurance reviewers will work in collaboration with each of the businesses to develop and monitor controls and other processes that mitigate identified risks. The UK Clinical Governance Team in conjunction with the Risk & Compliance Team will review each of the businesses risk registers on a monthly basis together with the submitted indicator dashboard. Business dashboards will be fed into the UK dashboard which has tolerances and limits assigned to each indicator. Out of appetite and tolerance indicators will be closely monitored and cross checked with risk registers. 5 Policy Date November 2016

6 The UK Clinical Governance Team will review the above information in conjunction with the first line reports and determine a specific risk review is required or if the annual business review timeframes are appropriate. Reporting of second line clinical governance assurance reviews will be reported into the UK Clinical & Information Risk Committee and ARCC. Third Line Assurance Review Internal audit is the third line of defense in Bupa and provides assurance that the other lines of defense are functioning effectively. Accordingly, internal audit will use the lines-of-defense process as a way of sharpening its value proposition by focusing its assurance activities more broadly on risk management. Internal audit reviews internal controls and risk management procedures; identifies risks, issues and improvement opportunities; makes recommendations; and keeps the Bupa Executive Risk Committee informed. Responsibilities of the Clinical Governance Assurance Review/Reviewer In addition to the guiding principles outlined above the additional responsibilities will be applicable to the reviewer/team: Developing an audit tool specific to the business Reviewing systems, processes and policies in place at a national and local level gaining assurance that processes are managed and relevant controls are in place, meeting internal and external regulatory requirements Reviewing businesses against regulatory requirements Responsible for providing guidance, support and direction for the businesses in their implementation of action plans and monitoring of implementation ensuring compliance and providing assurance oversight for the Bupa UK ARCC and appropriate Centre Medical committees To provide summarised reports to the ARCC To produce an annual report on the themes and trends of findings from business assurance reviews and submit a report to the UK Clinical & Information Risk Committee and the ARCC Methodology A routine programme of review visits will be scheduled for each of the businesses on an annual basis. The Bupa UK review team are experienced auditors and have therefore been empowered by the UK ARCC to make decisions and reach judgments about each service s performance set against the clinical and non-clinical regulatory requirements, requirements of relevant Bupa Enterprise policies and national and international best practice. Prior to each business review the review team will draft terms of reference which will include an outline a timetable for both the review and reporting of findings and what the expectations are for both the reviewer and business. 6 Policy Date November 2016

7 The review will start with an introductory meeting between the review team and the clinical governance team and other relevant staff of the business to discuss the logistics of the review and to reassure the service that the aim of the review is to provide the business with an independent assessment of the standards of practice within the service. Based on the needs of the business the review may be a combined clinical and non-clinical review with involvement from appropriate specialists. The UK Clinical Governance Team will take a triangulation approach when conducting a business clinical governance and risk assurance review or indeed any requested risk review. This triangulation approach consists of the following: 1. Review of Documentation: An example of the documentation reviewed as follows: Previous CQC and regulator inspection reports and action plans Previous UK Clinical Governance Team inspection reports and action plans Previous external accreditation audits and action plans Previous 12 months of incidents and complaints data including any RCA investigation reports. Monthly dashboards for the previous 12 months UK dashboard with tolerances and limits Departmental and business area risk registers Policies and procedures Training both clinical and non-clinical records and programmes Selection of personnel files for clinical and non-clinical staff Business clinical audit reports and list of business wide audits SLAs for external suppliers Minutes, actions and terms of reference for clinical governance, medicines governance, health & safety, infection control, blood transfusion, resuscitation and/or risk committees etc Customer, resident or patient medical records and if appropriate to speak directly with service users 2. Interview key members of staff within the business area An example of staff the UK Clinical Governance Team will interview is as follows: Clinical governance lead within the business Medical and nursing leads Risk and compliance lead Complaints leads Health & Safety lead Clinical leads for clinical areas such as pharmacy, infection control, operatig theatres, paediatrics, safeguarding, dental, GP service, physiotherapy, diagnostic imaging, laboratory, health advisors etc 7 Policy Date November 2016

8 Training lead Operational staff in clinical and non-clinical areas The Team may interview other relevant members of staff depending on the nature of thereview. During the interviews the Team will validate the information obtained from the documentation review. Staff will be assured that at no stage will the Team disclose which member of staff has informed them of specific findings unless it poses a risk to the business. 3. Review practices within the businesses The UK Clinical Governance Team will do an in depth tour of the businesses facilities once the first 2 stages have been completed. During this stage the Team will validate the information taken from the review of documentation and from the interviews with key staff. Once the visit is completed the reviewers will provide verbal feedback on their findings. Reports/ Action Plans/ Review The collated draft report detailing the review findings will be submitted to the appropriate personnel e.g. Clinical Governance Lead, Director of Quality or Nursing for review and confirmation of findings, within 20 working days, along with the suggested compliance level for each area reviewed. An overall compliance rating will also be given and the compliance scoring used in this policy is aligned to Centre Medical. Compliance RAYG Rationale A low or no degree of compliance, a start has been made but no evidence. A modest degree of compliance, work is ongoing, some evidence available. A significant degree of compliance, evidence is available, mostly met. Substantive of complete compliance. Evidence available. The business or service person will be required to review the draft report and provide comments within 10 working days. If no comments are received it will be assumed the report is accurate and will be finalised. Any challenges presented must be accompanied by evidence to support their assertion within 10 working days; otherwise the original findings will stand. Non-routine reviews may for example also include a proposed new business partner as part of the due diligence process. Such non-routine reviews will be conducted using a risk based approach (identified incident, complaints or claims trends, businesses risk registers, Clinical Executive Team risk register, immediately following a regulatory inspection, adverse media coverage or a review conducted by another UK function) and may be on request of the ARCC, UK Medical Director or the Director of Clinical Governance. Any recommendations made as a result of the review will require an action plan with agreed timeframes for completion and owners assigned to each action. Each business is responsible for developing the action plan. The UK Clinical Governance Team can provide support and guidance with the development of the action plan and can be part of the implementation team to close off actions and recommendations. The UK Clinical Governance Team will monitor the 8 Policy Date November 2016

9 progress of the action plan with a follow up review date agreed with the business or service. A summary of the findings and the compliance rating for reviews will be collated and form part of the ARCC clinical governance quarterly report and will also form part of the report presented to the UKMU Clinical & Information Risk Committee. 9 Policy Date November 2016