GOVERNANCE SMART objectives / SUHFT board development programme

Transcription

1 GOVERNANCE SMART objectives / SUHFT board development programme Specific objective Measurable Success Actions required Relevance / Outcome Owner Time Documented set of Trust Board objectives will be in place which have been discussed and agreed by BMs Board development programme is aligned to the outcome of work undertaken by Deloitte LLP / CE May board meeting Board development sessions, including attendance, documented Evidence of BMs commitment to development Sec May onwards 1 Board Performance Evaluation (which includes implementation of the Board and Development Programme) Board development programme in place and allows Board to constantly track progress against its objectives Board development session (external facilitator) to discuss: - the role of the board and attributes of a healthy board (in the health sector); - board to define its own goals and aspirations (distinct from those of the organisation) which are aimed at driving continual improvement of the board (link to board development session in objective 7) Board education session on the personal and corporate liabilities of directors Develop an process for future (whole board) evaluation Further develop the appraisal process for individual BMs Prior-board exec meetings to be diarised every month, with all executives (including non-voting) in attendance. Execs to continue with individual and team coaching. BMs will have an appreciation of the role of the board and NEDs in an FT environment and will understand what a good board looks like. BMs cognisant of the liabilities both for the board as a whole, and as individuals The board can demonstrate that the agreed objectives are used within the appraisal process for all BMs. Individual objectives are clearly aligned to those of the board (and documented) More time spent together as a team will lead to open debate and challenge key issues whilst execs become more aware of the work of colleagues. Increased level of challenge by execs at board meetings. by end Aug 5th September 06/06/2012 CE / CE CE by end Aug 5th September by end Sept

2 Use board development time to discuss: 2 Increase board insight and foresight so that all board members play a part in setting the organisation's strategy and objectives Annual Plan will be drawn from embedded vision, strategies, risk management structure and BAF. "No surprises". 1) strategy for growth 2) risk appetite (29th August 2012 / RSM) 3) emerging environmental and organisation issues, their associated sensitivities, impact and actions, contingency planning. use board agenda to plan strategic debate: 1) environmental and policy landscape / horizon scanning Development of supporting strategies, ensuring that they are fully integrated and aligned to service line reporting to provide info to support investment / disinvestment strategies, presented to board, including: IT Strategy Board members (BMs) should be able to articulate the vision of the organisation BMs will have common view on risk parameters the board is willing to accept BMs will have clearer understanding of external factors affecting the organisation At least a third of board meetings will be spent discussing strategy Board is able to demonstrate the link between strategies and supporting plans. Board discussion reflects understanding of integrated structure. Milestones for delivery in place, approval dates appear on board calendar, and specific risks to implementation on the risk register. MD end Aug by end Sept phased implementation to conclude by Feb /06/2012 tabled again 25 July 2012 to be tabled again 26 Sept /09/2012 Nov 2012 Financial Strategy ditto FD Workforce Strategy ditto DHR Aug-12 Data quality strategy ditto DO Jun-12 Risk strategy ditto CE complete Estates Strategy ditto DEF Dec-12 Quality Strategy ditto Jul-12 2

3 Assessment against Monitor's quality governance framework guidance for new FT's; results presented at board Board is aware of areas that require more attention and is able to focus resources to those areas Jul-12 Quality Strategy approved at Board Jul-12 All quality account priorities to be included in the board dashboard Quality drives the Trust's strategy 01/09/2012 October Trust complies with Monitor's Quality Governance Framework in all aspects An assessment of the Trust's quality governance framework against Monitor's quality guidance for new FT's will be carried out, and results presented to the Board. Thereafter, work carried out to fill residual gaps - see alongside. Quality appears high on each board agenda; board tracks quality KPIs each board meeting and board calendar reflects rolling programme of review, including quarterly reporting of risk register; Board development session: - core elements of quality governance - ensure board is aware of governors involvement in quality - agreement of top 3 quality priorities - understand how external benchmarks are used to assess quality - review metrics used for board reporting - reminder of quality governance processes and structures - briefing for NED quality walkabouts - overview of board to ward data process Board is sufficiently aware of potential risks to quality Board has necessary leadership, skill and knowledge to ensure delivery of the quality agenda Jul-12 3

4 Self assessment programme to be agreed Board has necessary leadership, skill and knowledge to ensure delivery of the quality agenda Initiated by end Dec 2012, completed by end March 2012 (to accommodate new board members) 3 Trust complies with Monitor's Quality Governance Framework in all aspects An assessment of the Trust's quality governance framework against Monitor's quality guidance for new FT's will be carried out, and results presented to the Board. Thereafter, work carried out to fill residual gaps - see alongside. Review: board clear about process for escalating quality performance issues to board (development session) Establishment of Clinical Audit Committee - monthly meetings - which holds business units to account for clinical governance issues Quality Assurance Committee - ToR review (RSM) Trust seeking to appoint NED with clinical / patient focus. Recruitment process to begin. NED with clinical background to be in post. Clearly defined, well understood processes for escalating and resolving issues and managing performance Clear roles and accountabilities in place Independent director on board with relevant experience. Sec / Governors / Governors Jul-12 complete end Sept to be updated as part of BAF methodology work Sept / Oct Jul-12 end Nov 2012 Review-board clear about process for escalating quality performance issues to board (development session) End of Q1 performance against quality account indicators published for staff and governors to view. Clearly defined, well understood processes for escalating and resolving issues and managing performance Board actively engages patients, staff and other key stakeholders on quality Jul-12 end August

5 3 Specific objective Measurable Success Actions required Relevance / Outcome Owner Time Trust complies with Monitor's Quality Governance Framework in all aspects An assessment of the Trust's quality governance framework against Monitor's quality guidance for new FT's will be carried out, and results presented to the Board. Thereafter, work carried out to fill residual gaps - see alongside. Use of Patient Experience Tracker enables patients to provide real time data, some of which is then used to inform board reporting Use of national Net Promoter Score Board actively engages patients, from May 2012 reported to Board monthly staff and other key stakeholders on quality Patient Story at board for first time. Aug-12 Quality Walks - currently involving CE and, to be extended to involve NEDs Verbal update at board meetings during finance report (CIPs) regarding Quality Impact assessments and those items that have been rejected on the grounds of quality. Post implementation review of QIA's for CIPs, with evidence of mitigating actions in place SI reports, complaints information, nursing indicators, PROMS, CQC updates, all continue to be presented at board on regular basis, as indicated on the board calendar Appropriate quality information is being analysed and challenged / CEO / PMO / July onwards Sept onwards From June onwards 01/08/2012 will be evidence at board for first time in October 2012 On-going Committee structures are constantly reviewed, with annual self evaluation on high level committees - CAC, etc Board committee structure is constantly reviewed, with annual self evaluation on high level committees - Audit, QAC Board is assured of the robustness of the quality information / Sec On-going On-going 5

6 Clinical audit programme driven by national audits and risk assessment, and results published annually in Quality Account New additional clinical audit function being set up: spec to be approved by Board for external tendering process. end June 2012 CE May-12 3 Trust complies with Monitor's Quality Governance Framework in all aspects An assessment of the Trust's quality governance framework against Monitor's quality guidance for new FT's will be carried out, and results presented to the Board. Thereafter, work carried out to fill residual gaps - see alongside. External clinical audit tender to be agreed and programme implemented 4Assurance (RSM Tenon electronic system) to be used to generate reliable reports for future board review. recruitment of data quality manager with responsibility for fixing incorrect data from DQ team to business units Data quality audit review to be undertaken. Information in 1/4ly and annual quality reports being displayed clearly and consistently Information to be humanised where possible (e.g. unexpected deaths shown as absolute number rather than embedded in a mortality rate) Continue use of 'round-up' on staff intranet to increase staff awareness of 'new' measures / guidance / policies Governance process (stering group) to be established to monitor the quality workstream work (including exec sponsors) Core Brief meetings have a 'Quality' agenda item for topical issues as they arise Board is assured of the robustness of the quality information Quality information is being used effectively. Board promotes a quality focussed culture throughout the Trust CEO / MD / DON DO DO execs Jan-13 Jan-13 completed Sep-12 June onwards Aug-12 6

7 Presentation of BU performance management framework to board Board can articulate how BUs are held to account and able to identify actions taken to address areas of under performance. DO May-12 4 Board assurance and holding to account Performance Management Framework for Business Units in place Review of governance arrangements in the BUs to ensure new performance management processes are understood and being adhered to, including: review of quality governance framework in specific areas including QAC Clear performance management process in place, with emphasis on Business Unit structure. DO Sep-12 Sep-12 7

8 Further board development session for BMs to address any residual concerns regarding the operation of the BAF (facilitated by RSM Tenon) BMs to be comfortable with the differences between the corporate risk register and the BAF. Clear processes and responsibilities in place relating to the Board's involvement with the BAF and Corporate Risk Register. / CE 06/06/2012 / CE 06/06/ Appropriate risk management processes, systems and culture are embedded within the organisation as a whole (strategic risk included here, organisational risk dealt with in separate SMART objectives) RSM Tenon Review (Sept 2012) reports that risk management systems have been fully implemented with heightened awareness of the management structures put in place. Board development session was held in June - further action arising - set up assurance framework meetings with RSM Tenon to carry out more work on the BAF, its workings, its content and overall 'fit' in the Trust's risk management structure Audit Committee and Quality Assurance Committee ToR's to be reviewed to ensure they align with new risk management strategy responsibilities relating to corporate risk register and BAF. BMs comfortable with the differences between the corporate risk register and BAF Clear processes and responsibilities in place relating to the Board's involvement with the BAF and Corporate Risk Register. Internal Audit annual report 2012/13 reports no weaknesses arising from the process of controls concerning the BAF. / CE Sec end commence Sept end commence Sept Risk appetite - see also objective 2 above. BMs will have common view on risk parameters the board is willing to accept / CE end August Board development session on the personal and corporate liabilities of directors (facilitated by Marsh) BMs to be fully cognisant of the liabilities and risks that their appointment may pose both for the board as a whole, and as 06/06/2012 8

9 RSM Tenon to undertake review of board finance reports Finance reports to be consistent with best practice FD completed Board workshop to review best practice from elsewhere across a range of board reports, clarifying improvements that will be made and what BMs want to see. To include development of a 'house style' report where appropriate. Board reports in general will reflect best practice in line with other FTs. Continue to develop 'house style' reports and covers for consistency of reporting end Aug 6 Improve board reporting and content of board reports Deloitte Board Governance Assurance Review in September 2012 will report improved clarity and consistency of board reports Continue to develop board reports to Format of all board reports is clearly articulate key risks and to increase amended where required to ensure the use of benchmarking, triangulation that they articulate the key risks and trend analysis. and draw the board's attention to To include reviewing and developing the areas of focus - report cover integrated performance report. sheets to link to BAF Continue to develop the integrated performance report. Performance failures can be forecast by use of trending analysis. Execs Execs Ensure BMs are aware of data quality testing and are cognisant of this when reviewing performance EDs can demonstrate tangible actions taken to improve the layout and content of their board reports DO May-12 Review process in place to ensure the board have reviewed and approve all key submissions to Monitor. All board approved submissions to Monitor appear on the board agenda and minutes reflect approval before submission. CE complete and ongoing 9

10 Board development session to discuss: - effective challenge; - assurance v reassurance; - operational v strategic (link to board development session in objective 1) by end Aug 5th September 7 Improve board engagement and the quality of challenge Deloitte Board Governance Assurance Review in September 2012 will report improved board engagement and quality of challenge from all board members Induction programmes for new Directors should be reviewed to ensure that board members - particularly those who have not previously held board positions - understand their role in board engagement and challenge BMs to have a clear understanding of how these attributes help to focus a board to become more effective by end October BMs should undertake individual coaching to address feedback provided as part of the Deloitte review BMs Exec board reports (written and verbal) should ensure that they clearly direct NEDs to the areas of greatest risk Execs feel held to account. CE 10

11 Increase the use of the board calendar to ensure sufficient time is given to debate and analysis of key risks and implications in advance of key decisions. (SEPS) SEPS should come to the board as a formal 'go / no go' decision supported by full options appraisal and risk analysis. BMs are confident that there are no outstanding issues before making well informed, risk assessed decisions Sec 01/05/2012 (pending formal SHA decision) 01/06/2012 (pending formal SHA decision) More effective use Board agendas reflect the of board agenda content of the board calendar 8 Board reports submitted by designated and forward plan with infrequent items appearing deadlines for decision making that are unplanned. Agendas do not show "to follow" items and papers subsequently received late by BMs Board papers / agendas show correct action sought from board i.e. approval, discussion, etc. / CE / CE Review content, style and length of board minutes Board minutes should be more succinct, consistent style Sec / complete Actions to be summarised at the end of each agenda item, actions placed on board action tracker with timescales and owners. Actions clearly evidenced, easy to follow, and reasoning given when timescales are not met or extended Sec / complete and ongoing 11

12 Included as part of 'organisational' SMART objectives 9 Improve data quality PAS procurement business case to be submitted to board PAS system replaced well in advance of April 2014, when current system ceases to be supported. MD May board Data quality report to be presented to the Board Board is fully aware of the issues relating to data quality and are made aware of plan of action to improve data quality throughout organisation. DO May board 12

13 Approve Terms of Reference for the Board complete (March) Directors' Register of Interests updated Sec complete (March) Matters reserved for the board' updated and approved by the Board complete (April) Split roles of and CE approved by the Board complete (April) Code of Conduct for Directors approved by the Board May board 10 Board Governance Structure Corporate documentation required by statute, regulation or in line with best practice, is in place SFI's and Scheme of Delegation to be reviewed by the Audit Committee before submission to board Standing Orders to be updated and approved by the Board Review of board sub-committee structure, including: - appropriateness of structure, and ensuring roles and remits are clear; -ToR's remain current and in-line with best practice; - membership of committees is appropriate; -improved reporting of sub-committee at Board. Appropriate and up to date documentation guides the Board in understanding its role, the parameters of its authority and mitigates the risk of financial and reputational loss, regulatory breach and personal liabilities for BMs FD end Sept calendared for November Update and approval (in conjunction with the Governors) of Constitution end Sept Oct 13

14 11 Explore Board dynamics Deloitte Board Governance Assurance Review in September 2012 will report better interaction between board members Workshop aimed at developing the Board as a team (exploring personality preferences, the skills and experiences of individual board members, and agreeing behaviours not covered by the Code of Conduct.) Set up 'time out sessions' for whole board to seek to build relationships in an informal environment Clearer understanding amongst BMs of the styles and strengths of Board colleagues 14

15 Impact of the Board to Ward programme should be kept under review (see also objective 3) The Board can point to improvements made as a result of the 'Board to Ward' programme July onwards 12 Visibility of the Board Increased instances of board visibility and engagement with staff, patients and key stakeholders Board to agree a structured programme of events to increase the profile of the Board with staff, patients and key stakeholders, including: - Schedule of monthly visits by BMs to outlying clinics / sites to allow engagement with staff / patients away from main site - Staff and patients will be able to recognise BMs and to articulate their role and appreciate the impact of the work of the Board CE - from August, included in CE / verbal report Promote board meetings and agendas more widely Wider range of stakeholders feel 'welcome' to attend board meetings and are able to understand Trust strategy and direction / Sec. / Comms June onwards 15

16 This document should not be read in isolation; several objectives cited in this document are linked to those that are detailed in the separate 'organisational' objectives already agreed by the Board. For example, objective 5 herein relating to risk management is aimed more at the management of strategic risk and how risk relates specifically to the Board, as opposed to the roll out of risk management processes throughout the organisation, which is dealt with separately. It should also be noted that although dates are provided herein for accomplishment of projects, this does not mean that the matter is thereafter 'lost' from sight of the Board. On-going monitoring, improvement, review and updating will continue to take place where appropriate. For example, objective 2 refers to the approval of certain strategies - once approved, the strategies will continue to be monitored and reviewed at appropriate intervals, thus reflecting the dynamic nature of the Board's vision and role. 16

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