Report Title: Trust Board Assurance Committees, Quality Assurance Framework and Assurance Mapping

Transcription

1 Summary Report Trust Board Meeting Date: 27 th March 2013 (Part 1) Report Title: Trust Board Assurance s, Quality Assurance Framework and Assurance Mapping Agenda Item: 09 Enclosures: Sponsor; Medical Director and Executive Director of Nursing and Quality Report Author: Hayley Richards, Hazel Watson and Emma Roberts Report discussed previously at: Presenter: Medical Director and NCAS Director Chair of Audit & Chair of Quality and Standards have been invited to contribute comments Purpose of the Report and Action required To present the direction of travel for the Board s Quality Assurance Framework, and the Assurance s following discussion during the first part of The Board is asked to: Adopt the framework outlined below in order for it to form the basis of ongoing work relating to quality assurance. Consider the re-focusing of the role of the Assurance s in relation to quality assurance framework; Note the interrelationships between the key governance elements; Note the Assurance Map; Discuss the key systems that the s should review during the year; Approval Discussion Information X X Executive Summary of Key Issues The Francis Report and Monitor Provider License requires a thorough review of the way Board s obtain assurance, and the effectiveness of the systems and processes to evidence assurance. The Board wishes to define its governance arrangements in a quality assurance framework. This piece of work has been led by the Medical Director and Director of Nursing & Quality and will continue to be explored through further consultation. Alongside the Quality Improvement Plan and Quality Information System, the Quality Assurance Framework, allows us to be clear about lines of responsibility and reporting. Each of the Board s focus will be realigned to assuring the Board that the key systems and processes operating within the Trust are effective and robust. This change will result in less outcome based information being presented to the s and thus reduce duplication between the Senior Management Team of the Trust and Assurance s; The key systems will be described and tested through a range of functions including internal and external audit, clinical audit, peer review and management review. The exact

2 Assurance s and Assurance Mapping form of assessment will be decided based on a risk assessment of the systems; The changing role of the Assurance s will impact on their membership, purpose, objectives and work plans for the year and these will be developed over the next few weeks. At the same time, the management or internal governance groups of the Trust Executive have been reviewed again, and rationalised further (the Board noted the first rationalised position in the summer of 2012). The new internal governance arrangements are mapped out in the attached appendix and the attached assurance map shows interrelationships between management groups, systems, and the Assurance s. This work will continue to be refined following contributions from experts, staff, stakeholders and the Board. Which Strategic Objective does this paper address A sustainable value for money business Excellent service user access and experience Excellent partnership working with other organisations Effective engagement and improvement in staff satisfaction Y Link to Fit for the Future Implementation Plan Specify objective number n/a Recommendations to other committees n/a Recommendation/Decision The Board is recommended to note the report. Agenda Item: 09 Serial: Page 2 of 16

3 Assurance s and Assurance Mapping 1. Purpose 1.1 A key component of ensuring the Board s fitness for purpose is to oversee the Corporate Governance systems within the Trust and ensure they meet the requirements of the Trust both now and as a Foundation Trust and support the effective functioning of the Board. The Monitor Provider License requires the Board to have in place arrangements for effective board and committee structures, clear reporting lines and accountabilities throughout organisations. 1.2 In March 2013 the Company Secretary, Director of Nursing and Medical Director met with key individuals to finalise work to deliver a Quality Assurance Framework which met the requirements of a well governed Foundation Trust. 1.3 The Chairs of the Quality and Safety and the Audit & Risk discussed and contributed to the thinking during a period of consultation which has involved a very wide range of staff. The Board is now asked to consider this framework, inviting contributions in relation to how it will be finessed further. 2 Changing Role of the Assurance s 2.1 The Chair has required that the Board s are refocused so as to enable the Board to operate at its most effective. Appropriate levels of stress testing in of the effectiveness of the Trust s systems and processes, enables the Board to be assured of the effectiveness of its overall arrangements. The Chair has made explicit the need for Chairs to ensure the Board exercises its role diligently, requiring the right level of information, without delving into operational areas inappropriately. 2.2 The role of the Assurance s is to assure the Trust Board that the systems and processes supporting delivery of the Trust s objectives, both strategic and operational, are effective and robust. This will be aligned with the new quality information system being introduced. The proposed changes require the focus of the Assurance s to move away from outcomes to the processes which deliver those outcomes. The focus can be described as follows: Assurance Delivery Process/system 1 Process/system 2 Process/system 3 Process/system 4 Outcomes Report for the Avon & Wiltshire Process/system Mental Health 5 Partnership Trust Board 27 th March 2013 Agenda Item: 09 Serial: Page 3 of 16

4 Assurance s and Assurance Mapping 2.3 As described in the above system chart, processes are created to deliver defined outcomes. The Trust Board is responsible for the delivery of the outcomes and delegates authority for the creation and delivery of the systems and processes to the Executive Management Team. 2.4 The outcomes are monitored through the Quality Information system and are overseen by the Senior Management Team. 2.5 The Trust Board maintains an oversight and responsibility for the systems, but the effectiveness and appropriateness of the systems and processes need to be stress tested by the Assurance s. 2.6 The process undertaken for the mapping of the effectiveness and robustness of the systems and processes is as follows: Identify the key systems and processes operating in the Trust, see Appendix 1; Align these systems and processes to one of the Assurance s; Align the systems and processes with the management groups identified as overseeing the data outputs from each system. At the same time refreshing the aims and terms of reference of each management group and reenergising the reporting relationship with the Executive Team/Trustwide Management Group. Build the testing and interrogation of these systems into the workplan of the Assurance s during the year based on a risk assessed priority order. Based on the systems identified and the risks linked to each system the programme maybe expanded over a number of years; Identify suitable methods for testing and interrogating systems. This may include utilising internal audit, clinical audit, peer review, management review and using existing external audit processes. Cross reference the robustness of systems to the outcomes being delivered and identify areas for improvement; 2.7 The benefits of this approach in defining our quality assurance framework are: Reduced duplication between operational delivery reporting and the Assurance s; A focus on interrogation of systems and process which will drive their improvement. This will be seen in the improvements in related outcomes; Clear focus for the groups based on a prioritisation of key critical systems; Revised membership allowing for appropriate focus on assurance and efficiency of workload for some senior managers; 2.8 An additional valid role for the s is in reviewing, in further detail, a specific issue or problem that the Board recognises as needing additional focus. These bespoke pieces of work will be commissioned by the Board as part of its business. The Board will be required to report back to the Board, closing the loop on matters of governance, in a way that has, sometimes been less robust in the past. Agenda Item: 09 Serial: Page 4 of 16

5 Assurance s and Assurance Mapping 3 Impact of Changes on the existing s Quality and Standards 3.1 The proposed Quality and Standards with bring together the Mental Health Legislation with Quality and Safety. It will be required to change its focus towards testing the critical systems it has identified and which are set out overleaf. 3.2 This will also allow the more appropriate realignment of the management groups to report to the Senior Management Team. 3.3 In addition the membership has been reviewed for all Assurance s to reflect changes among the Executive Directors and Non Executive Body. 3.4 The focus of the will be in relation to the following workstreams: Quality Improvement Safety Safeguarding Patient experience Mental Health Legislation Learning from events, reviews, incidents etc Regulatory Compliance - by exception only 3.5 In defining its new way of working, this has demanded a clear Quality Assurance Framework, within which key critical systems are defined. In addition, the roles of the Management Groups and Locality Governance Groups are to be defined so as to ensure appropriate accountabilities rest with those leading systems and outcomes. This work is referenced later in the report. Audit and Risk 3.6 As previously agreed at Board, the Audit and Risk has responsibility for the following workstreams which do not change: Internal Control Risk Management Corporate Governance Systems Information Governance Legal and Regulatory Compliance Finance and Planning 3.7 The Finance and Planning has responsibility for the following workstreams which do not change: Financial Planning Agenda Item: 09 Serial: Page 5 of 16

6 Assurance s and Assurance Mapping Develop Trust plans for changes in the financial regime. Business Development Strategy. Scrutinise capital and revenue business cases. Business partnering arrangements and possible tenders. Performance and activity and its impact on the Trust Finances. Employee Strategy and Engagement 3.8 The Employee Strategy and Engagement has responsibility for the following workstreams which do not change : Workforce planning framework Talent Management, Succession Planning arrangements Organisational Development strategy Workforce strategy 4. Key Critical Systems 4.1 The following systems have been identified as critical by the Executive Team. Each of these systems provides data and outputs which will be reviewed by one of the Management Groups of the Trust. The anticipated alignments have been mapped in Appendix The role of the Assurance s will be to review or stress test the effectiveness of the systems and processes, based on information relating to effectiveness of the outputs. 4.3 Once the review of systems is complete the systems will be prioritised for review, system owners identified and systems described. Finance and Planning Systems(Business Executive Lead) Quality Information System deliberately in twice with Clin Exec Lead? Finance Information System (Agresso) Performance Framework Business Planning Framework Workforce Procedures o Recruitment o Appraisal and Supervision o Training o Sickness Absence Management Equality & Diversity Procedures Health & Safety Guidance and assessment processes Commercial Development Framework Communications and Stakeholder engagement framework Policy Management system Quality and Standards systems (Clinical Executive Lead) Incident Management and Reporting (Ulysses) Quality Improvement Framework and Strategy Agenda Item: 09 Serial: Page 6 of 16

7 Assurance s and Assurance Mapping Quality Information System Clinical Academy Clinical Coding CQC Compliance (CQC PCA and Quality Information System) NHSLA Compliance framework Clinical Audit Medical Records Audit and Risk(Clinical and Business Executive Lead) Financial Management and Reporting arrangements Risk Management process (Ulysees) Decision Making SO s, SFI s, Scheme of Delegation Responsiveness to Internal Audit & External Audit Recommendations Capital Prioritisation Information Governance Framework and Toolkit Monitor compliance reporting Internal control and Audit Employee Strategy and Engagement (Business Executive Lead) Sickness reporting system Electronic staff record Supervision and appraisal system (Inspire) Workforce planning tools and frameworks 5. Assurance Mapping and the new Framework 5.1 A process of assurance mapping has been started and will continue over time. The attached map sets out the alignment between key critical systems, the Board s and the new Management Groups of the Trust. The Trust s systems expert, Dr Julie Hankin will support this work, and we will work with external experts from neighbouring Trusts. 5.2 The terms of reference of the new Management Groups are due to be approved via the Senior Management Team of the Trust and have been shared with the Chair of Audit & Risk and Chair of Quality and Standards for completeness. 5.3 New Chairs have been identified for each of the Management Groups who will be responsible for co-ordinating the onward process of system mapping as referred to above. 5.4 The new management groups will be implemented with effect from 1 April At the same time, the Trustwide Management Group will become the Senior Management Team. 5.5 The Professional Council will become Clinical Cabinet. The way the Clinical Cabinet is being considered by clinical colleagues and will be implemented formally from 1 April The management groups are mapped in the attached diagram at Appendix 1. Agenda Item: 09 Serial: Page 7 of 16

8 Assurance s and Assurance Mapping 6. Conclusions 6.1 The framework depicts the way in which the Board operates, the role of the Board s moving forward, and the interrelationships between the component parts of the governance framework. The work will continue to be finessed and alongside the Quality Improvement Plan and Quality Information System, will enable the Board to be sighted on its routes of assurance, and the systems which offer it. 7. Recommendations The Board is invited to discuss the framework, to offer contributions and thoughts as to its further iteration, and to adopt it. Agenda Item: 09 Serial: Page 8 of 16

9 Trust Board FT Steering Group Senior Management Team Quality and Standards Finance and Planning Employee Strategy and Engagement Audit and Risk Nominations General Negotiating Group Clinical Cabinet Service User and Carer Steering Group Investment Planning Group Information Governance Group Critical Incident Overview Group Performance and Contracts Group denotes alignment between groups denotes a reporting arrangement Health, Safety and Fire Group Business Systems Group Denotes Board or Board Denotes management Group Infection Control, Physical Healthcare and Medical Devices Clinical Systems Group Mental Health Legislation Mgt Group Medicines

10 Appendix 2 - System Description Template Purpose of the System Why is the system in place, what benefit does it bring to the organisation? Brief Description of the System Brief description of how the system operates System Owner (Executive and Operational Lead) Who are the Executive and Operational Owners of the system? System Inputs What information is fed into the system and from where? System Outputs What are the outputs of the system i.e. reports, plans etc? Assurance Checks How is the system checked for robustness? i.e. Internal Audit, External Audit, Clinical Audit, owner testing, peer review? Links to Other Systems Which other systems does this system link to? Key Documentation/ IT Systems What are the key documents that describe this system in more detail or include relevant information? What are the key IT systems which assist the operation of the system?

11 Appendix 3 Assurance Mapping Avon and Wiltshire Mental Health Partnership NHS Trust Quality Assurance Map (draft March 2013) Assurance Function Area of Assurance Management Group oversight Internal System providing assurance External Validation source Quality and Standards Compliance with regulatory provisions Oversee delivery of high quality safe patient care Review Quality Strategy Review systems for monitoring incidents and clinical risks Oversee the framework of Clinical Audit Oversee the system of compliance with Health and Safety Issues Health Fire and Safety Health and Safety reporting Clinical Incidents CIOG Quarterly incident reports Serious Incidents CIOG Monthly Incident Reports Medical Devices Infection Control, Physical Healthcare and Medical Devices Safeguarding Infection Control Mental Health Legislation Mgt Group Infection Control, Physical Healthcare and Medical Devices Safeguarding reports Quarterly reports Health and Safety Executive CNST Safeguarding Board CNST PEAT Reports

12 mental health act administration Review trends in patient satisfaction Assurance s and Assurance Mapping NICE Clinical Cabinet Quarterly reports Survey data Quality Information System Medicines Medicines Management Quarterly reports Audit Management Safe Staffing Levels Clinical Cabinet Quarterly reports Quality Information System CQC Compliance Senior Management Team Quality Information CQC System Reports Mental Health Legislation Compliance Mental Health Legislation Mgt Group Mental Health Act Administration Reports CQC Clinical Audit Clinical Cabinet Clinical Audit Programme Internal Audit Audit and Risk Oversee effectiveness of system of internal control Oversee effectiveness of systems of clinical and corporate risk Encourage relationships Risk Management Senior Management Team Risk Management System and Registers Internal Audit Senior Management Team Internal Audit Programme External Audit Senior Management Team Annual Governance Statement Internal Audit annual assessment External Audit External Audit opinion Agenda Item: 09 Serial: Page 12 of 16

13 with External Audit Oversee systems of corporate governance Oversee information governance arrangements of the Trust Assurance s and Assurance Mapping Monitor Compliance Senior Management Team Monitor Dashboard Monitor quarterly returns Information Governance compliance Information Governance Group IG toolkit Information Commissioner reports A Oversee the development of the Business Development Strategy Oversee proposed business partnering arrangements and possible tenders. Scrutinise delivery of performance and activity and its impact on the Trust Finances. Financial planning review Senior Management Team Business Plan/Annual Plan Market analysis Performance and Contracts Group Market Analysis review and Pestle/SWOT Business Development Monitor Audit Senior Management Team Finance Reports Audit Agenda Item: 09 Serial: Page 13 of 16

14 Review capital and revenue planning. Oversee the development of the Financial Plan Contract management Performance management Finance activity review Capital and Revenue business cases Business support systems Assurance s and Assurance Mapping Performance and Contracts Group Performance and Contracts Group Senior Management Team Investment Planning Group Business Systems Group Quality Information system Quality Information system Quality Information System Investment Policy and monthly finance reports Quarterly reporting to Senior Management Team Audit Audit Audit Audit Internal Audit Employee Strategy and Engagement Oversee the development of the workforce planning framework and annual workforce plans Oversee development of plans for talent management, succession planning, staff engagement performance Workforce Strategy Senior Management Team Quarterly reports of the Dir of HR Talent Management Strategy Senior Management Team Reports to the Nominations NHS Employers Monitor Agenda Item: 09 Serial: Page 14 of 16

15 and reward and recognition Monitor plans for the modernisation of the workforce and organisational development strategy and plans Assure and provide advice on the HR issues associated with any proposed external partnership opportunities and plans Workforce development framework Assurance s and Assurance Mapping Senior Management Team Quarterly reports of the Dir of HR HR Strategy Performance and Contracts Group Business Development Framework NHS Employers Audit Agenda Item: 09 Serial: Page 15 of 16

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