Board Assurance And Escalation Framework

Transcription

1 Board Assurance And Escalation Framework

2 CONTENTS 1.0 Introduction 2.0 Definition of Quality 3.0 Purpose 4.0 Culture 5.0 Staff involvement 6.0 Patients/carers/public involvement 7.0 Internal and external sources of assessment/assurance 8.0 Commissioners and NHS Midlands and East 9.0 Trust s Internal Performance and Quality Monitoring 10.0 Decision-making and escalation 11.0 Trust s Risk Monitoring Escalation and Assurance framework 12.0 Structures 13.0 Monitoring of action plans 14.0 Organisational learning Appendices 1. Integrated Planning, Performance and Risk Management framework 2. Information flows to support decision-making and assurance process 3. Risk Management Structure 4. Risk Escalation Process 5. Board Governance Structure 6. Role and Function of Key s 7. Governance & Quality sub-groups 8. CQC Escalation Process 9. Quality Improvement Process 10. Quality Account Process 11. Cost Improvement Plan Process Version control: Author: Mandy Edwards, FT Project Manager Version 10.0 Draft Document 7 th May 2012

3 1. Introduction Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has developed a range of policies, systems and processes which, when drawn together, comprise a robust governance structure which provides a framework for the assurance and escalation of quality within the Trust. This document describes this assurance and escalation framework and demonstrates how the Trust s quality systems and learning from events is monitored by an effective committee structure. It also illustrates how this process links to Monitor s Quality Governance requirements which are structured around the four pillars; strategy, capability and culture, processes and structures and measurement. This provides the Board with assurance about how the organisation is able to identify, monitor, escalate and manage quality concerns in a timely fashion and at an appropriate level. 2. Definition of Quality The Trust s Quality Improvement Strategy describes quality by reference to High Quality Care for All published in June 2008 and the government white paper, Equity and Excellence: Liberating the NHS which states that quality should be at the heart of the NHS. To bring clarity to quality, the Trust has developed a clear definition of quality and quality governance using the three dimensions of quality defined in High Quality Care for All. It also reflects Monitor s definition of quality governance as being the combination of structures and processes at and below board level to lead on trust-wide quality performance. The National Quality Board s paper Quality Governance in the NHS A guide for provider Boards uses Monitor s quality governance framework to provide clarity to Boards and acts as a route map to support Boards to deliver improved quality and outcomes and this has been used as a key document to support the quality journey. 3. Purpose This framework describes the Trust s quality governance structure, systems and performance indicators through which the Trust Board receives assurance. It also describes the process for the escalation of concerns or risks which could threaten delivery of the Trust s quality objectives, service delivery or patient safety. The Trust s overall integrated planning, performance and risk management framework is set out in Appendix Culture The Trust has an open, honest and learning culture, which is described in its Whistleblowing policy. The Trust encourages the reporting of all adverse incidents by its staff and the reporting of complaints and concerns by patients, their carers and relatives.

4 5. Staff Involvement The Trust has a number of policies and systems which encourage staff at all levels to be involved in performance monitoring and to raise concerns about any risk issues. These include: Whistleblowing and Being Open policy HR Policies Safeguarding Policies (Children and vulnerable adults) Staff Surveys Ask Gary "Hear Me" telephone hotline for staff Staff Partnership Forum Risk Management Strategy Risk Management Policy Serious Incidents Requiring Investigation (SIRI) Policy Incident Policy Quality Improvement Strategy and Quality Matters Framework Aggregating Data and Learning from Incidents, Serious Untoward Incidents, Complaints and Claims Process The incident, near-miss and serious untoward incident policy The complaints policy CQC/NHSLA compliance against standards (including self-assessments) Information Governance policies and processes Appraisals and Performance Development Process Monthly Performance meetings for Service Lines and quarterly performance review meetings for Heads of Service 6. Patients/Carers/Public Involvement The Trust has a Board approved Service Experience Strategy that includes a comprehensive implementation plan, which has been developed to address both national and local drivers. The Trust encourages patients and/or their carers and the public to make comments and/or raise concerns both formally and informally via a number of mechanisms, such as: Compliments Patient and carer experience surveys Patient Stories Patient Experience Tracker Tools LINks (Local Involvement Networks) Local Authority Health Overview and Scrutiny Service Experience Desk which includes Patient Advice and Liaison Service (PALS) and Complaints, both formal and informal Service User and Carer forum Stakeholder Forum Patient Environment Assessment Team (PEAT) Ward Representatives

5 Patient Advocacy Experts By Experience (EBE) The Trust positively engages with patients and/or their carers and the public and welcomes their involvement and feedback on how they can become better involved in the Trust s decision making process. 7. Internal & External Sources of Assessment/Assurance Internal and external sources of assessment/assurance cover the range of the Trust s activities and include: Audit Commission (review of Quality Account) Internal Audit (review of internal systems and processes) Commissioner Appreciative Enquiries Specialty reviews (e.g. Care Quality Commission) National Audits (e.g. Diabetes, Falls) Independent Reviews (e.g. Ombudsman reports) Network reviews (e.g. QIPP) Patient and carer experience surveys Patient Stories Patient Experience Tracker Tools LINks (Local Involvement Networks) Local Authority Health Overview and Scrutiny Service Experience Desk which includes Patient Advice and Liaison Service (PALS) and Complaints, both formal and informal Service User and Carer forum Stakeholder Forum Mental Health Act Scrutiny Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations Accreditation for Inpatient Mental Health Services (AIMS) Electro Convulsive Therapy Accreditation Service (ECTAS) Safe Effective Quality Occupational Health Service (SEQOHS) accreditation Code of Hygiene compliance Patient Environment Action Team (PEAT) assessments West Midlands Quality Review Service NHS Litigation Authority (NHSLA) Compliance Information Governance Toolkit Audit Commission National Benchmarking club Cost Improvement Plan (CIP) and Service Transformation Quality Impact Assessments (QIA) The Trust also commissions external reviews of its activities/services where the need for additional independent assessment/assurance is identified. 8. Commissioners & NHS Midlands And East

6 In addition to the internal routes for raising concerns and risk, there are formal mechanisms by which the commissioners and strategic health authority can raise concerns. These include: Board to Board meetings (NHS Midlands and East) CRM - Contract Review Meeting (Commissioners) CQM - Clinical Quality Meeting (Commissioners) Provider Management Regime (PMR) for aspirant Foundation Trusts GP Concerns SUI Process Patient Safety Incidents reported via NRLS (National Patient Safety Agency reporting and learning system) West Midlands Quality Review Mental Health Programme Board SHA Quality & Safety Review of aspirant Foundation Trusts 9. Trust s Internal Quality and Performance Monitoring 9.1. The Trust has a number of forums where performance and quality are discussed, and these are detailed in Appendix 2. The key performance meetings are the contract activity review meeting (CARM) held monthly, corporate finance & performance committee (F&P) held monthly, governance & quality committee (G&Q) held monthly and service performance reviews held quarterly. The service performance review meetings cover a number of domains focussed around a set agenda. These cover: Service Performance, focusing on: Access Demand Productivity and efficiency Quality and Safety Workforce Finance Service User/Carer Experience Cost Improvement Programme (CIP) Contractual requirements e.g. QIPP and CQUIN Service developments The Contract Activity Review Meetings provide the opportunity to feed into the corporate Finance and Performance meeting, supported by comprehensive, RAG-rated dashboards to inform discussion. Reporting of key issues adversely affecting performance is done on an exception basis, and any key risks or areas of performance requiring escalation are brought to the fortnightly Management Executive Team meetings to be managed accordingly.

7 The Governance and Quality receive performance information and intelligence relating to all aspects of governance, quality, safety, patient experience, risk and regulation. Reporting is on an exception basis and any key risks or issues are reported through to Trust Board Desktop Performance Dashboard A desktop performance dashboard has been in place since Q2 2011, which details a range of performance and quality indicators with the most recent day s, week s or month s performance against target, on a RAG-rated basis. Data in the warehouse is refreshed every day, and so provides almost real time performance information. Each KPI in the dashboard drills down to team and patient level to identify breaches in a few clicks. The dashboard enables monitoring of internal, external (local and national) KPI s and data quality/completeness indicators Integrated Performance Report An integrated performance report has been in place since Q3 2011, which details a range of indicators with their most recent month s performance against target, on a RAG-rated basis. The content of the report is reviewed regularly and covers those areas of performance and quality that have been reported through the escalation process and/or which are subject to scrutiny by commissioners. The report is reported monthly to CARM and F&P Top Level Integrated Performance Dashboard The Integrated Performance Dashboard and report are reported monthly to the Trust Board and provide assurance around the Trust s performance in relation to a number of key areas including: Monitor s Compliance Framework NHS Midlands and East Provider Management Regime (PMR) Contractual requirements with NHS Dudley & NHS Walsall Patient safety and quality Key corporate performance indicators Data quality Any areas of adverse performance are reported to the Board based on the monthly Contract Activity Review Meetings and the monthly corporate Finance & Performance and Governance & Quality meeting discussions, and include remedial actions to address issues with a timescale for delivery. The Governance & Quality is regularly updated on the self assessment against the Essential Standards, informed of any areas of non-compliance and provided with assurance that steps are being taken to ensure compliance Management and Monitoring The integrated performance report is monitored at CARM. Risks and exceptions are escalated to Management Executive Team (MExT) for remedial action and reported to Finance and Performance to provide assurance to the Board.

8 The governance exception report is monitored at Governance & Quality and risks and exceptions escalated via Management Executive Team (MExT) for remedial action and reported to Finance and Performance to provide assurance to the Board (see committee structure at appendix 5& 7) Cost Improvement Plans The Trust has in place a process for the development and monitoring of Cost Improvement Plans (CIP) which includes the establishment of a robust Project Initiation Document (PID) for each individual CIP scheme including a Quality Impact Assessment (QIA). This is described in Appendix Quality Strategy and Account The Trust has in place a Quality Improvement Strategy the implementation of which is supported by a Quality Matters Framework and annual Quality Improvement Plan. The delivery of the continuous quality improvement described by the strategy, framework and plan is underpinned by the Quality Improvement process as set out in Appendix 9. The Trust s annual Quality Account provides a report to the public about the quality of the services the Trust provides and the progress against its strategic and annual quality objectives. It gives opportunity for scrutiny on how the Trust performs in relation to quality and sets out the focussed areas for quality improvement for the forthcoming year. Assurance is required on the Trust s Quality Account from the lead Commissioner and from the Trust s external auditors, the Audit Commission. The Trust s annual Quality Improvement Plan is monitored by the Governance and Quality. Appendix 10 describes the process for developing, reviewing and reporting the quality account Service Experience Strategy A key element of the Trust s quality monitoring is listening and responding to feedback from service users and carers, together with engagement and involvement in the Trust s performance and development. The Service Experience Strategy is central to delivering high quality, responsive services and identifies three key approaches to ensure this: Listen - to people s experiences and views Respond - comprehensively to feedback through investigation and analysis of feedback, communicating findings & identifying actions Demonstrate - what has improved as a result, through reporting feedback demonstrating learning and committing to improvement based on real patient consultation. The strategy is underpinned by an effective Service Experience Desk, which collates and reports on performance in relation to service user experience. Individual reports for each Service Line are presented quarterly at Service Line Quality meetings. The information and narrative of this report then forms the basis of the MExT (quarterly), Governance & Quality (monthly) and Trust Board (6 monthly) reports.

9 As well as a number of formal forums where service user and carer representatives are core members e.g. Service User & Carer Forum, Stakeholder Forum, Governance & Quality, representation is encouraged on operational workstreams and Trust events such as annual staff awards. 10. Decision Making and Escalation Monitoring compliance against Care Quality Commission (CQC) Essential Standards The Trust undertakes a regular programme of self assessments against the CQC Essential Standards. This involves the Trust s Clinical Governance Facilitator liaising with Team and Departmental managers to ensure that ongoing compliance is evidenced via departmental CQC workbooks. The Governance and Quality receives exception reports on the progress of self-assessments, and any areas of non-compliance or with compliance concerns. The exception reports also provide assurance against the steps being taken to ensure compliance is achieved. A CQC escalation process has been developed to ensure decisions are made at an appropriate level to ensure that quality of care and patient safety are guaranteed at all times (see Appendix 8). 11. Trust s Risk Monitoring Escalation & Assurance Framework (See Appendix 3) The Trust operates 5 tiers of risk management (including the Board assurance Framework) which are all interlinked via an escalation process (Appendix 4). The escalation of a risk is dependent upon the level of the risk, or on whether it is felt that the risk needs specialist management at a higher tier, such as the risk requiring a multi directorate approach to management Local and Directorate Risk Logs/Registers (Tiers 1 3) These are linked to risk assessment, incidents, complaints and SUI s. Corporate and Operational Services have a process in place to keep their risk registers updated. They provide updates on the content of their risk registers monthly to the Governance Manager for inclusion into the Trust Wide Risk Register (TWRR) where appropriate. Risks are reviewed within a stated time frame by the local teams to ensure that controls in place are effective, and assess whether the risk changes over time. Risks may be identified through internal processes e.g. complaints, incidents, claims, service delivery changes, risk assessments or financial interests. They may also be identified by external factors e.g. national reports and recommendations Trust Wide Risk Register (TWRR) Escalation from Directorate Risk Registers of risks scoring more than 15 and additional risks requiring multi directorate/disciplinary approach.

10 The Trust Wide Risk Register is the aggregation of the local team risk logs/registers and directorate risk registers where the residual risk is more than 15. It includes any additional sources of risk such as external or internal reviews. It is maintained centrally by the Trust Governance Manager. It identifies the source, describes the risk, scores and grades it and provides a summary of the action taken to control it. It includes a review date and a residual risk rating Board Assurance Framework (BAF) Escalation from TWRR and additional strategic risks scoring more than 16. The Trust s Board Assurance Framework (BAF) underpins the delivery of its key objectives and incorporates the highest risks faced by the organisation. It therefore aligns the Trust s principal risks with the key controls and assurances for each of the Trust s key objectives. Where gaps in assurances are identified, mitigating actions are developed to reduce the risk of the non-delivery of these key objectives. The BAF is reviewed on a quarterly basis by the Trust Board and includes all red operational risks. The BAF also includes those risks that have been identified as strategic risks central to the delivery of the Trust s core activities. The formation and development of the BAF is the responsibility of the Director of People and Corporate Development and is overseen by the Strategic Planning Manager, who provides advice on strategic risks to the organisation. Strategic risks are identified by the Board and reviewed quarterly together with the BAF and progress on delivery of corporate objectives. The Board Assurance Framework provides a vehicle for the Trust Board to be assured that the systems, polices and people in place are operating in a way that is effective and focussed on the key risks which might prevent the Trust objectives being achieved Management and monitoring of the BAF Risk is managed at all levels, both up and down the organization. Refer to Risk Management Strategy for details. (See appendices 3 and 4 for escalation process) The Board Assurance Framework (BAF) is monitored on a quarterly cycle. In order to ensure triangulation between the annual plan and the BAF, the Trust produces an integrated report to the Finance and Performance and to the Trust Board. Part 1 Performance against objectives (annual plan performance review) Reports on the progress made against each of the 16 high-level annual objectives and highlights any KPI s or milestones not being met i.e. triangulation with the performance framework. It concludes with a RAG rating of the likelihood that the objective will be delivered. Part 2 Assurances on the management of risks related to achieving objectives (BAF) Presents the controls and assurances around the principal risks that may impact the delivery of the annual objectives and, more importantly, the strategic objectives. Each risk is linked to a Trust objective and has an

11 Executive lead, responsible for receiving assurance that the actions required to mitigate the risk are completed at either local operational or strategic level. 12. Structures (See Appendices 5 & 6) 13. Monitoring of Action Plans The Trust has a robust process of monitoring actions arising from external reviews, internal audit reports and SUIs and high level assessments which also hold individuals to account to deliver a number of initiatives (e.g. Service Transformation, Foundation Trust status, CIPs and corporate objectives). Various committees are tasked with monitoring these action plans which are part of their work plans, these include; Audit : Actions from Internal Audit Reports, Counter Fraud Governance & Quality : Actions from; CQC, NHSLA, Information Governance, Clinical Audit, External Quality Reviews (E.g WMQR), C.Difficile, Norovirus Finance & Performance : 18 weeks, Occupied Bed days, CIPs, Corporate Objectives Foundation Trust Programme Board: FT Action Plans, Membership, TFA Service Transformation Programme Board: Service Transformation projects, clinical vacancies, CIPs, ST QIA, service reviews 14. Organisational Learning The Trust is committed to learning from incidents and complaints in a culture that is open and transparent, and share this learning across the organisation. This is achieved in a number of ways; On-going reporting and analysis of data concerning incidents, serious untoward incidents, complaints and claims through the Governance Department Regular reporting of analysis and trends to key s and the Trust Board Regular identification of key learning for professionals and teams On-going discussion, monitoring and review by the Embedding Lessons Group Publication of the minutes of the Trust Board (via the Trust Intranet) Dissemination of minutes of key committees such as the Safeguarding, the Health and Safety, the Infection Control, the Medicines Management and the Embedding Lessons Group. Monthly communication and information sharing through the Commissioner Review Meetings in Dudley and Walsall. Communication from the Governance Department detailing lessons learnt through the Team Brief communication newsletter. Awareness raising posters and materials via the Governance Department. Embedding Lessons Folders within clinical teams.

12 Appendix 1 - Integrated Planning, Performance and Risk Management Framework Appendix 2 - Information flows to support decision-making and assurance process

13 Trust Board Stakeholder Forum Mental Health Act Scrutiny Audit Contract Activity Review Meeting Finance & Performance Safeguarding Strategic Group Governance & Quality Health & Safety FT Programme Board Service Transformation Programme Board MExT Capital Planning Meeting Information Governance Medicines Management Workforce & OD Operational Financial Clinical Trust Board Director Governance Performance Service User/Carer Workforce Communications Service User & Carer Reference Group Embedding Lessons Group Service Line Governance & Quality Groups Clinical Audit & Effectiveness Regulation & Risk Working Group Equality & Diversity The diagram is intended to illustrate the performance, quality and safety information flows within the Trust which support the decision making and assurance processes. It is therefore not a comprehensive organisational structure chart. The coloured dots indicate the organisational representation at key forums and thus the multidimensional nature of information flows within the Trust.

14 Appendix 3 - Risk Management Structure Risks are identified at a local level and escalated, depending on score, to the next appropriate level.

15 Appendix 4 Risk escalation process Risks Managed (risk score) Responsibility Tier of risk Register Risks that are rated low (Risk Score of 1 5) where it is felt this risk can be managed locally. Risks that are rated medium (Risk Score of 6 12) and risks that are rated low (1 5) where it is felt that the risk cannot be managed locally and requires a multi departmental approach to the management of risk. Risks within the Directorate that are rated as a high risk (15 25) where it is felt that the risk can be managed within the Directorate and risks that are rated as a medium risk (6 12) where it is felt that the appropriate director needs to take ownership of the risk. The risk is the responsibility of the identified owner (Appropriate Managers, Team Leaders, head of department) The risk is the responsibility of the identified owner (Appropriate Manager, Team Leader, Associate Director) The risk is the responsibility of the identified owner (in this case Director) Local Risk Logs (Tier 5) Local Risk Registers (Tier 4) Directorate Risk Registers (Tier 3) There may be risks identified which require committee ownership as well as individuals. These are assimilated by the Regulation and Risk Working Group and will form part of the Trust wide risk register and in some instances the Board Assurance Framework, these are outlined below. Risks Managed (risk score) Risks that are rated as a high risk (15 25) and medium risks (6 12), that require a multi-directorate approach to manage the risk. Those risks that have been identified as strategic risks to the organisation and those risks identified by the Trusts Governance and Quality as requiring Trust Board ownership Responsibility of individuals and The risk is the responsibility of the appropriate Director and is monitored by the Trusts Governance and Quality The risk is the responsibility of the Trust Board. Tier of risk Register Trust Wide Risk Register (Tier 2) Board Assurance Framework

16 Appendix 5 - Board Governance Structure TRUST BOARD Finance & Performance Governance & Quality Audit Mental Health Act Scrutiny *Charitable Funds Remuneration & Terms of Service *NB the role of the Charitable Funds is performed for each borough s charitable funds via the respective PCT s Charitable Funds. The work of the Trust Board and its s is underpinned by the work of the Management Executive Team meeting (MExT) which under the chairmanship of the Chief Executive oversees the operational functions of the Trust.

17 Appendix 6 - Role and Function of Key s Board Sub- Audit Finance and Performance Governance and Quality Membership Frequency Principal Functions from Terms of Reference reports received 3 Non- Executive Directors 3 Non- Executive Directors Chief Executive Director of Finance, Estates and IM&T 2 Non- Executive Directors All Executive directors Associate Directors - Operations Associate Directors Medical Professional Leads Functional Heads Service User and Carer reps At least quarterly Monthly Monthly Review the effectiveness of integrated governance and internal control across the Trust. Ensure an effective internal audit function that meets regulatory standards. Review the work and findings of the appointed external audit function. Review the findings of other significant assurance functions Review the financial statements and annual report prior to the Board. Ensure adequate arrangements for countering fraud and review the outcomes of counter fraud work Review all aspects of financial management arrangements Review performance against key operational and contractual targets Review performance of each locality/ business unit. Review key financial strategies, policies and plans Review significant business cases for the development, amendment or cessation of services. Monitor assessment, compliance, assurances and evidence in support of national evaluations and assessments Monitor the assessment and compliance against NHSLA and CQC essential standards. Ensure systematic opportunities for patient, carer and public participation are embedded Ensure compliance with relevant regulatory, legal and code of conduct requirements. Lead committee for overseeing development, implementation and monitoring of the Quality Framework and Quality accounts Monitor external reviews, enquiries, surveys and investigations, and lessons learned. Monitor service quality and patient experience to ensure action is taken, lessons are learned and disseminated. Monitor the function and compliance of the risk management policy, principles and assurance framework. None Estates and Capital Planning Group Contract Activity Review Meeting Health and Safety Infection Control Information Governance group Policies and Procedures group Service User and Carer Reference group Clinical Audit and Effectiveness group R&D group Medicines Management Equality and Diversity group Safeguarding group

18 Board Sub- Mental Health Act Scrutiny Remuneration & Terms of Service Charitable Funds Membership Frequency Principal Functions from Terms of Reference reports received 2 Non- At least Executive quarterly Directors Mental Health Act Administration Leads Director of People and Corporate Development Chair and 2 Non- Executive Directors 1 per annum, as required To ensure that the Trust meets all of its requirements under the Mental Health Act. To be responsible for the development, review and implementation of Mental Health Act policies and procedure to support compliance with legislation. To ensure that recommendations made in response to the Mental Health Act Commission (MHAC) reports are actioned appropriately. To monitor the role and performance of the Associate Lay Managers under the Act. To review and monitor the use of the Act within the Trust, noting and further investigating any trends with respect to locality, gender, age, ethnicity and cultural background. Set and review the terms and conditions of Board-level directors (except Non-Executive Directors) Monitor and evaluate the performance of Board-level Directors (excluding Non- Executive Directors) Authorise any non-contractual payments for None None all employees. The role of the Charitable Funds is performed for each localities charitable funds via the respective PCT s Charitable Funds. Whilst MExT is not a formal sub-committee of the Board it performs a valuable operational role and for completeness its membership, functions and the committee reports it receives are shown below: Membership Frequency Principal Functions from Terms of Reference Management Executive Team (MExT) All Executive directors. Associate Directors - Operations Associate Directors Medical Professional Leads Functional Heads Fortnightly Act as the main operational board of the Trust, making decisions that ensure the effective implementation of Trust strategy, monitoring outcomes and providing assurance of progress. Monitor the work of the Locality Management Meetings and Acute Care Forum. Receive and agree formal business cases to deliver strategic plans. To act as the main forum within which the interface of clinical and non-clinical services is addressed. reports received OD & workforce Service Transformatio n Community Operational Management Meeting DONs Business Opportunities Team Quality Performance Review meetings

19 Appendix 7 - Governance & Quality sub groups Trust Board Governance & Quality Safeguarding Strategic Group Medicines Management Information Governance Group Infection Control Health & Safety Regulation & Risk Working Group Policies & Procedures Focus Group Service Line Governance & Quality Groups (5) Research & Development Group Service User & Carer Reference Group Embedding Lessons Group Clinical Audit & Effectiveness Group Equality & Diversity Group

20 Appendix 8 CQC Escalation Process Identified Area of no compliance with CQC Standards Via spot check audits / whistle-blowing / incident reporting / serious Incident / complaint or internal assessments / other route Added to local risk registers Escalated to Board and added onto Trust Wide Risk Register and monitored by Board in line with Trust RM processes Revised Action Plan developed / Overseen by Executive Director Continued non compliance with standards Report to CQC and / SHA / Commissioners if patient safety compromised and / or service suspended Issue escalated to Team manager / Head of Service and raised to GQC Added to Directorate Risk Register if deemed appropriate Identified Actions Implemented and compliance with standards assessed Further actions implemented and Issue fully addressed or service suspended / terminated Action Plan developed by Team and monitored by Clinical Governance Department / nominated staff member / committee Identified Actions Implemented and compliance with standards assessed Or Issue fully addressed escalation process stopped and ongoing monitoring continues Continued non compliance with standards Or Issue fully addressed escalation process stopped and ongoing monitoring continues Continued non compliance with standards

21 Quality Intelligence Appendix 9 - Quality Improvement Process To deliver the continuous quality improvement required by the Trust s Quality Strategy and framework the Trust has adopted the process outlined below. This process will be applied across the Trust and also for each service line. This process will be in line with the strategic direction of Trust and aim to address key areas of risk. It will be a live process that is communicated widely and will result in the delivery of high quality services and assist with the production of the Trust s annual Quality Account. Process Outcome Process 1 Aggregated Analysis of core data (SI s, complaints, incidents and performance) data) Outcome 1 Awareness of areas requiring improvement Process 2 Agreement of changes required and methodology to be used, key milestones and identified Trust lead Outcome 2 Signed off Project Initiation Plan Process 3 Process of involvement commences in line with project plan impact of changes Outcome 3 Improved services/ procedures Process 4 Utilisation and analysis of data intelligence to ensure services have improved Outcome 4 Assurance that services have improved

22 Appendix 10 - Quality Account Process Review quality performance Publish the information and commit to improvement Identify areas for improvement Leads To - Leads To - Public accountability Leadership engaged with improvement of quality of services

23 Appendix 11 Cost Improvement Plan (CIP) process CIP ownership Named individuals for each scheme: Board sponsor Project Manager Lead Clinician Finance and HR leads CIP structure CIP Scheme Identified: Name of Scheme Financial Target Directorate/corporate area Project scope Link to Corporate Objectives Impact on Patient Pathway Commissioning CIP PID PID Assessment of: Benefits operational, clinical, financial Risks clinical (QIA), financial & regulatory risks and mitigations Stakeholder Involvement who are they and what do they require Milestones and monitoring timing, reporting process Workforce impact on staffing levels Communications plan with identified leads