Royal Devon & Exeter NHS Foundation Trust Governance Review

Transcription

1 Royal Devon & Exeter NHS Foundation Trust Governance Review Em Wilkinson-Brice Director of Nursing & Patient Care Suzanne Tracey Director of Finance & Business Development Richard Schofield Corporate Affairs Manager

2 Programme National Context and Drivers Hallmarks of Good Governance Methodology Governance - review & proposal Board Assurance Framework - review & proposal Audit review & proposal Debate Next Steps

3 National Context and Drivers Good Housekeeping A different style of regulation CQC focus on outcomes / Quality Risk Profile / Inspection Regime Mid Staffordshire - Increased scrutiny of patient safety and quality of care White Paper reforms Outcomes Framework Financial pressures ensuring Best Care and Best Value Monitor Quality Governance Framework consultation on amendments to the Compliance Framework

4 Monitor Quality Governance Framework

5 There is no shortage of guidance... Assurance The Board Agenda (2002) The Integrated Governance Handbook (2006) Taking it on Trust (2009) The Healthy NHS Board (2010)

6 The Hallmarks of Good Governance: The Healthy NHS Board A clear strategy Ensuring accountability Holding the organisation to account for its performance in the delivery of the strategy Seeking assurance that systems of control are robust and reliable Quality assurance and clinical governance Financial stewardship Risk management through the assurance framework

7 The Hallmarks of Good Governance: Taking it on Trust Good assurance: requires the right governance framework to be in place requires internal controls, effective risk management and a good assurance framework is required on internal controls requires good data quality

8 Review Methodology Executive commissioned Internal Audit to undertake a: Stocktake of existing governance processes Identify significant gaps or areas for development Methodology Review of best practice Comparison against best practice Consideration and comparison of audit work across other organisations Consultation with Executive and discussion with Chairs of Audit & Governance & Board Chairman Debate at the Board

9 Governance John Rackstraw Em Wilkinson-Brice

10 Governance Our Assessment Key part of Governance Framework Guidance is set out in: Integrated Governance Handbook DH 2006 Taking it on Trust Best practice guidance is for this committee to review risk register and assurance framework and ensure risk / assurance processes work effectively, passing, through a clear workplan. Each Trust has its own way of operating.

11 Structure 31 groups/committees report to the Governance 3 further committees whose TOR identify that they report to the Governance. At least a further 15 sub-committees. A number of terms of reference require review and updating. Structure could be rationalised and streamlined

12 Royal Devon & Exeter NHS Foundation Trust Structure Membership Development Group Constitutional Review Working Gp Rules & Procedures Working Gp Appraisal Working Gp Capital Control Group OMG Council of Governors Attendance Non- Executive Remuneration Trust Executive PMG Appointments Nominations Fit for the Future Staff Engagement and Communication Group Charitable Funds Strategic Redesign Programme Board Strategic Redesign Programme Working Group Project Steering Groups (10) Project Delivery Team Meetings Governance Audit Board of Directors Executive Remuneration Disability Equality Action Group Disability Equality Action Group Involving People Steering Group PPI Steering Group Processes for admission Clinical Audit & Effectiveness Comm PPI Working Group - Carers issues effective care of patients specific requirements Decontamination Comm Environment & Waste Management Group Fire Safety Health & Safety Hospital Transfusion Infection Control National Standards Local Strategy (NSLS) Non-Medical Professional Governance Comm Environment Action Team Productive Ward Steering Group Compete Emergency preparedness Steering Radiation Safety Comm Resuscitation Security Forum Security Operational Group Patient Environmental Action Group Exec Group Directorate Governance Groups (11 groups) The Exeter Area Joint Formulary Drugs & Therapeutics Comm Medical Devises Steering Group Anti-microbial Sub-committee Medical Products Evaluation Sub-Group Safeguarding of Adults from Abuse Point of Care Testing Sub-Group Steering group Patient Safety Steering Group Adverse Events Forum Information Governance Steering Group IG Security Forum Diversity Steering Comm Diversity Lea Forum Medicines Management ED vulnerable Children Meeting Strategic Safeguarding Child Protection Forum Key Trustwide Children Children Champion Direct Reporting Line Indirect Reporting Line Indicates that is direct line report as per Gov TOR Other s/internal Groups Directorate one to ones Central training monies Quarterly reviews Ardentia project board Medical Staff * Intranet board meeting Paediatrics Sub-direct Nutrition Steering Group* Pharmacy redesign SLM* Community hospitals RTT steering group The Productive Operating Theatre ESR and rostopro DM meetings Venous Thrombolprophylaxis (VTE) Security at Ward Level Group Theatre management Discharge summary Emergency patient flow Lead nurse Eliminating mixed sex wards ewtd junior doctors Concourse operations Concourse signage Annual members meeting * Uncertain whether groups still meets

13 Governance Areas for Development Room for improvement Role of the committee should be redefined structure should be rationalised. Workplan should be reviewed in light of the need to consider more strategic risks and CQC assessments? The forum to consider and triangulate data from its sub-structure answering the questions..

14 Governance Areas for Development What does the data really tell us? Can the provide assurance to the Board? Does the need to commission further work from its sub-structure to provide assurance?

15 Governance Safeguarding Clinical Effectiveness Workforce and Diversity Safety & Risk Directorate Governance Groups Engagement Function Ensure delivery of Safeguarding Strategy Function To review clinical guidance inc. NICE, & provide assurance of effective clinical practice Function Ensure delivery of workforce strategy Function Ensure delivery of Risk Strategy Function To lead governance in the directorate Function Ensure delivery of Engagement Strategy Vulnerable adults Child protection Domestic Violence Dementia Learning Disability Clinical Audit Drugs & Therapeutics Resuscitation Medical Devices Workforce planning & Development Educational Commissioning OD & employee relations Staff engagement & Wellbeing Workforce Equality & Diversity Incident reporting, Investigation & analysis Review escalated risks & provide corporate support/action Receive a schedule of reports escalation of unresolved/ unacceptable risks Provide assurance of effective governance Manage directorate risk register Escalate unmanaged risk to Safety & Risk Duty to consult PPI Patient Experience - ensure action taken as a result of feedback Engagement with all Stakeholders inc hard to reach

16 Governance Safeguarding Clinical Effectiveness Workforce and Diversity Safety & Risk Directorate Governance Groups Engagement /Experience Child Protection Ops Group Clinical Guidelines committee DEAG Directorate Risk Groups Patient Experience Group ED Vulnerable Child Meeting Medicines Management Central Training Monies Information Gov Group IPSG Dementia Steering Group Drugs & Therapeutic committee Health & Safety Vulnerable Adults Steering Group (inc LD) Nutrition Steering Group Security Forum Domestic Abuse Ops Group Hospital Transfusion Fire Safety Resus Patient Safety Programme Group Medical Devices Adverse Events Group (New ToR) VTE Group Radiation Protection Group Emergency Preparedness Steering Group Infection control

17 Board Assurance Framework Richard Schofield

18 Assurance Framework - Guidance Assurance The Board Agenda Department of Health, July 2002 Building the Assurance Framework Department of Health, March 2003 Sets out requirement to maintain the assurance framework. Sets out some basic guidance as to content. Guidance as to content is updated each year by the Department of Health in its year end SIC guidance. Taking it on Trust Audit Commission, April 2009 The Integrated Governance Handbook Department of Health 2006 Board Assurance Frameworks The Good Governance Institute, March 2009 More detailed guidance, reiterating benefits of the assurance framework, context behind it and providing advice and best practice examples of how to maintain and develop the framework.

19 Extract from Board Assurance Frameworks Assurance Framework Provides a structure & process that enables the organisation to focus on risks that might compromise its most important objectives and to map the key controls that should be in place to manage.. and confirm that the Board has sufficient assurances about the effectiveness of these controls.

20 Assurance Framework Extract from The Healthy NHS Board The most effective Boards use the Board Assurance Framework as a dynamic tool to drive the board agenda.

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22 Assurance Framework Expectations Department of Health / Monitor expectation. Central to the Governance Framework. Link corporate objectives to risks / provide assurance to Board as to management of these risks. Not an add-on process should be central to the boards agenda. Living document updated regularly, based on identification of risk by the Board. Should drive work of the audit committee, and be monitored by an appropriate committee. Board should be engaged in defining the corporate / strategic risks. Should be clarity of ownership and maintenance. Identify assurances / controls in sufficient detail - Should identify gaps in either control or assurance.

23 Board Assurance Framework (BAF) Our Assessment There needs to be much clear linkage between the BAF and strategic objectives, with the BAF concentrating on corporate strategic risk Roles and responsibilities need to be clearly defined.

24 Board Assurance Framework (BAF) Our Assessment More detail on controls and assurances would add further clarity Almost no gaps are recorded Scope to show more context re; movement of risks and remedial risks.

25 Board Assurance Framework Areas for Development The way the framework is maintained is there a need for one single point of responsibility for the framework? The need to clearly define the roles and expectations to ensure clarity over the roles of the Board, Audit and Governance around the framework. Alignment of BAF to operational planning cycle and Board planning cycle.

26 Board Assurance Framework Areas for Development Format of the framework use of trend data to show risk profile over a period of time / indication of residual risk How strategic /corporate risks are captured at Board level Level of detail regarding controls in place, assurances, and identified gaps Documenting and mapping independent sources of assurance

27 Board Assurance Framework Proposal Corporate Affairs to be responsible for maintaining the BAF A new format of BAF A new risk reporting matrix to be incorporated into the Integrated Performance Report

28 Audit David Robertson Suzanne Tracey

29 Audit Our Assessment The role of the audit committee has moved on from looking at purely financial controls to considering the whole system of internal control Role of Audit - Checking the Checkers

30 Audit Handbook Independently monitors, reviews and reports to Board on processes of governance Should review disclosure statements, in particular statement of internal control (and declaration for CQC?) prior to approval by Board Should use Assurance Framework as its central tool for planning its work Should use both management and auditors to give it assurance that the way of managing risks is effective Another key role is to review, agree and recommend to Board approval of annual report and accounts. should review risks and controls around financial management (particularly robustness of monitoring management accounts and board reports)

31 Audit Assessment against best practice The committee does not review the Board Assurance Framework (BAF) on a regular basis Many committees actively review the framework and test the content to assess the process. This function could be further developed Role of scrutinising disclosure statements could be strengthened Many organisations support the committee through a corporate secretary or executive responsible for the BAF. Seen as a valuable link between the committee and the management function. Allows effective management of the workplan, development and consideration of new risks / latest guidance. Most organisations use a formal report to the Board. A written report from the committee chair provides clarity and is more valuable than simply presenting the minutes.

32 Further development Audit Action Taken Number of meetings increased to 4 per annum Forward plan established to include: Review of Assurance Framework and link to setting workplans for auditors Review of statement of internal control Review of governance arrangements Corporate Affairs Manager appointed as secretary to Decision briefings (formal report) made from Audit to Board of Directors after each meeting Action to be taken to consider any further development of its role in respect of the Assurance Framework Decision needs to be taken by Board re role of Audit in reviewing disclosure statements (Monitor Declaration) Clarification required as what form the Board would wish to receive an annual review of governance arrangements from the Audit Annual meeting between External Auditors & Chairman

33 Debate What is the Board s shared understanding of delegated responsibility re; governance? Governance Audit What is the Board s view of further areas for development? How will we evaluate the changes?

34 Next Steps