Patient Experience, Quality and Safety Committee: Self-assessment Questionnaire Summary Assessment

Transcription

1 Patient Experience, Quality and Safety Committee: Self-assessment Questionnaire Summary Assessment Area Composition and Establishment Areas Where Urgent Improvement is Needed Issues to form part of a Committee Development Programme Practice Worth Sharing Action Agreed Effective Functioning Committee Effective Functioning Individual Members Compliance with the Law and Regulations Governing the NHS Assurance Standards for Health and Care in Wales, Effectiveness and Patient Safety Administrative Arrangements PEQ&S Committee: Self Assessment Page 1 of 5

2 COMPOSITION AND ESTABLISHMENT 1) Does the Committee have written terms of reference that adequately and realistically define its role, purpose and accountabilities? 2) Have the terms of reference been formally adopted by the Board? 3) Are the terms of reference reviewed annually to ensure that they remain fit for purpose? 4) Does the Committee have an annual work plan in place that covers all relevant areas? 5) Has the Committee been provided with sufficient membership, authority and resources to perform its role effectively and independently? 6) Does the Committee have the requisite number of Non Officer Members? 7) Does the Committee membership include appropriate representatives from the organisations stakeholders? EFFECTIVE FUNCTIONING COMMITTEE 8) Is there effective scrutiny and challenge from all Committee members? 9) Does the board review the progress and outputs of the Committee? 10) Does the Committee report regularly to the Board verbally and through minutes and make clear recommendations when necessary? PEQ&S Committee: Self Assessment Page 2 of 5

3 11) Does the Committee have arrangements in place to ensure that its work is fully conveyed to the wider organisation? 12) Does the Committee periodically assess its own effectiveness? 13) Do members give appropriate feedback on the effectiveness of the Chair and the Board Secretary? 14) Has the Committee determined the appropriate level of detail it wishes to receive from reports? 15) Does the Committee receive the appropriate level of timely and accurate information to allow it to fulfil its role? 16) Does the Committee effectively monitor - or ensure the monitoring of - agreed actions e.g. by use of the action grid? 17) Are members particularly those new to the Committee, provided with training? 18) Has the Committee formally considered how it integrates with other committees and groups? 19) Does the Committee receive timely and appropriate feedback from its sub-groups? 20) Does the Committee provide clear direction to its sub-groups? 21) Do all members contribute to and review the Committee s annual report? 22) Are the relevant members of the Executive Team represented at Committee meetings? 24) Are arrangements in place to call ad hoc meetings when necessary? 25) Are arrangements in place to notify Committee members of urgent matters? PEQ&S Committee: Self Assessment Page 3 of 5

4 26) Does the Committee make the organisation aware of issues of staff capacity and skills that impact on the running of the Committee? EFFECTIVE FUNCTIONING INDIVIDUAL MEMBERS 27) Do all members have an understanding and knowledge of the issues to identify patient safety issues? 28) Do all members appropriately challenge Executives and management on critical and sensitive matters? COMPLIANCE WITH THE LAW AND REGULATIONS GOVERNING THE NHS 29) Does the Committee have a mechanism in place to keep it aware of topical issues? 30) Does the Committee have a mechanism in place to keep it up to date and aware of legal issues? ASSURANCE 31) Does the Committee receive timely exception reports about the work of external regulatory and inspection bodies? 32) Does the Committee receive timely information on performance concerns? 33) Has the Committee received training/awareness raising in relation to the standards and legislation applicable to the role of the Committee? PEQ&S Committee: Self Assessment Page 4 of 5

5 34) Does the Committee receive regular reports from and meet with Wales Audit Office, Healthcare Inspectorate Wales and other external bodies? HEALTH AND CARE STANDARDS IN WALES, EFFECTIVENESS AND PATIENT SAFETY 35) Has the Board clearly articulated which Standards the Committee is responsible for? 36) Has the Board clearly defined its expectations of the Committee in relation to the designated aspects of the Health and Care Standards? 37) Does the Committee play a part in developing the strategies for workforce and OD and other methods for improvement? 38) Does the Committee seek assurance that the organisation has effective systems for reporting, investigating and learning from workforce and OD incidents? 39) Does the Committee contribute to the commissioning/delivery of safe, effective and timely patient care? 40) Does the Committee manage the balance between accountability for standards and managing risk while encouraging creativity and innovation? ADMINISTRATIVE ARRANGEMENTS 41) Has the Committee considered the costs that it incurs; and are the costs appropriate to the perceived risks and benefits? 42) Are papers circulated in good time and are minutes received as soon as possible after meetings? PEQ&S Committee: Self Assessment Page 5 of 5