Policy:E7. Escalation Policy N/A. Appended below at Appendix B. Version: E7/01

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1 Policy:E7 Escalation Policy Version: E7/01 Ratified by: Trust Management Team Date ratified: 11 th September 2013 Title of Author: Board Secretary & Head of Governance Title of responsible Director Medical Director Governance Quality Assurance Date issued: 18 th October 2013 Review date: July 2015 Target audience: All staff NHSLA relevant? N/A Disclosure Status Can be disclosed to patients and the public EIA / Sustainability N/A Implementation Plan Monitoring Plan Appended below at Appendix B Other Related Procedure or Documents: West London Mental Health NHS Trust Page 1 of 13

2 Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 13

3 E7 Escalation Policy Version Control Sheet Version Date Title of Author Status Comment E7/01 July 13 Board Secretary / Head of Governance New policy Under consultation, ending To be presented to September TMT. Approved West London Mental Health NHS Trust Page 3 of 13

4 Content Page No. 1. Introduction 5 2. Scope 5 3. Definitions Duties Board Chief Executive Executive Director Accountable Director Managers Policy Author Local Policy Leads All Staff Process Raising Concerns Sources of Assessment & Assurance 8. Monitoring 8 7. Training Fraud Statement References (External Documents) Supporting Documents Glossary of Terms/Acronyms Appendices Appendix A Governance Structure Appendix B Monitoring Template West London Mental Health NHS Trust Page 4 of 13

5 1. INTRODUCTION 1.1 The West London Mental Health Trust has developed a range of policies, systems and processes, which together comprise a robust and integrated escalation policy. 1.2 The escalation policy sets out how the Trust Board receives assurance regarding the quality of its services and/or identified issues or problems. It describes or signposts various policies, systems and processes, including - risk management - quality & cost improvement strategy - complaints - whistleblowing - incident reporting - performance management framework & reporting 2. SCOPE 2.1 The escalation policy ensures that the Trust s quality performance across the range of its activities is monitored and managed; resulting in targets being met, objectives achieved, programmes of work being kept on track and good outcomes delivered for patients. It also addresses under-performance and ensures that potential performance problems are identified early and rectified. Operationally, this is delivered via the Trust s performance management framework. 2.2 The policy describes the formal governance structure and systems through which the Board receives assurance or escalated concerns / risks related to the Trust s performance and other, informal sources of assurance The Trust s governance structure is set out at Appendix A. 3. DEFINITIONS 3.1 Escalation to increase in this case to increase the level at which issues or performance are scrutinised, within the Trust 3.2 Governance consistent management, cohesive policies, guidance, processes and decision-rights for a given area of responsibility 3.3 Assurance processes designed to ensure the quality of a product or service 3.4 Quality High Quality Care for All (published in 2008) outlined that quality should include three dimensions: patient safety, patient experience, effectiveness of care. These three dimensions encompass the key aspects of clinical quality and they will underpin our quality strategy and be reflected in our governance framework. 4. DUTIES 4.1 Trust Board The Trust Board is responsible for ensuring that the Escalation Policy is implemented across the organisation and that it has assurance processes in place to this effect. West London Mental Health NHS Trust Page 5 of 13

6 4.2 Chief Executive The Chief Executive is responsible for ensuring that the Trust s systems, processes and policies to support the Escalation Policy are in place and that the organisation complies with its legal and regulatory obligations. 4.3 Executive Directors The Executive Directors are responsible for ensuring the effective operation of the Escalation Policy processes in their directorates. 4.4 Accountable Director The accountable director (the Medical Director) is responsible for the development of this policy and for ensuring it complies with NHSLA standards and criteria as applicable. They are also responsible for overseeing trustwide implementation and compliance with the policy. 4.5 Managers Managers are responsible for ensuring the policy is communicated to their teams and ultimately cascaded to all staff. They are responsible for ensuring staff attend any relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are up to date, implemented and monitored. 4. Policy Author The policy author (Head of Governance) is responsible for the development / review of the policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU / Directorate leads and that monitoring arrangements are robust. 4.7 Local Policy Leads Local policy leads are responsible for ensuring this policy is communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing any monitoring reports. Areas of poor performance should be raised at the CSU / Directorate SMT meetings. 4.8 All Staff All staff are responsible for making themselves aware of the provisions of this Escalation Policy and the associated systems, processes and policies, and for acting in accordance with them. All staff have a responsibility to raise concerns initially with their immediate manager / supervisor where appropriate to do so. 5. PROCESS 5.1 Raising Concerns The Trust has an open and learning culture (see the Being Open Policy) and encourages monitoring of, and comments and concerns about, its performance from a wide range of internal and external sources. West London Mental Health NHS Trust Page of 13

7 5.1.1 Staff 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: Policies - Whistleblowing (W1) - HR policies i.e. Grievance (G1), Disciplinary (D4) - Incident Reporting & Management Policy (I8) - Safeguarding policies (re Children (C18), Adults (S28) - Risk Management Policy (R1) and Risk Management Strategy - Counter Fraud Policy & Reporting Procedure (F2) Processes - Management Supervision - Clinical Supervision - PDR / Appraisal Process - Board Visits - Staff Surveys - Trade Unions / Staff Side representation Service Users & Carers Service Users and/or their carers are encouraged to make comments and/or raise concerns both formally and informally via a number of mechanisms, such as: - PALS (Patient Advice and Liaison Service) - Complaints, Compliments and Concerns Policy - Patient Satisfaction Survey - Electronic Patient Feedback System Meridian - NHS Choices - Patient Choice - Health watch - Local Authority Health Overview and Scrutiny - User representative on committees and meetings across the Trust including the Service Users and Carers Forums Commissioners & Other External Stakeholders There are a range of external stakeholders who will use their own mechanisms for feedback to the Trust. These include: - Auditors (internal & external auditors) - Care Quality Commission - Clinical Commissioning Groups (CCG) - Council of Governors (once elected) - General Practitioners - Health and Wellbeing Boards - LATs - London Deanery - Local Partnership Forums - Local Education and Training Boards - Local Health Watch - Local Health Overview and Scrutiny s - Nursing & Midwifery Council - National Commissioning Board and Local Area Teams - NHS Litigation Authority West London Mental Health NHS Trust Page 7 of 13

8 - Public Health England - Quality Surveillance Groups - Regulatory Bodies - the Media 5.2 Sources of Assessment & Assurance Internal and External Sources of Assessment / Assurance Internal and external sources of assessment / assurance cover the range of the Trust s activities and include: Internal - Key Performance Indicators - Chair s Reports / minutes of other meetings - Staff Survey Results - Patient Satisfaction Surveys - Safeguarding Serious Case Reviews - Internal Management Reviews - Serious Incident Review Reports - Clinical Audit - Clinical Presentations from staff, service users, carers External - Health and Safety Inspections - National Patient Satisfaction Surveys - National Benchmarking for mental health trusts - Independent Reviews - CQC Quality Risk Profile - Clinical Governance Peer Reviews - National Staff Survey - Internal Audit Reports - External Audit Reports - National Audits - Counter Fraud Specialist Reports - CQC reviews (including Mental Health Act Commissioner monitoring visits) - TDA performance managing - NHSLA assessments - CCG / Commissioners contract monitoring meetings (including CQUIN) - Validation meetings - Peer review process (currently being piloted in Broadmoor Hospital) - High secure hospitals quarterly key performance indicator benchmarking The Trust will also commission external reviews of its activities where the need for additional independent assessments / assurance is identified.. MONITORING.1 Key Performance Indicators (KPIs) In holding the executive to account for the delivery of the strategic objectives and the operational performance of the Trust; the Board will oversee a range of Key Performance Indicators (KPIs). The KPIs will cover the breadth of the Trust s activities. West London Mental Health NHS Trust Page 8 of 13

9 .1.1 The Board s KPIs are determined in part by the external regulatory framework, e.g. - Monitor s Compliance Framework - The Accountability Framework (NTDA) - CQC Essential Standards.1.2 The Board may also identify and monitor KPIs associated with the delivery of its strategy or the monitoring of identified risk. These indicators may change over time as particular issues come to the fore for the Trust..1.3 The Board will determine its information requirements to enable it to; - identify issues that need to be reported routinely to the Board at a certain level of detail. - identify issues that need to be reported only if there is demonstrably a problem, for example, where performance significantly diverges from that achieved by peer trusts. - identify issues that change relatively slowly and that should therefore be looked at only on a quarterly or six-monthly basis - monitor trends in performance against trajectory in terms of finance and business development, quality and the experience of patients - compare the Trust s performance with peer organisations - forecast and anticipate future performance issues spot early warnings of potential financial or other problems - identify significant risks, issues and exceptions - make relevant and constructive challenge - make informed decisions - develop its understanding of the organisation.2 Performance Management.2.1 The Board assimilates selected KPIs into a high level, integrated report. This enables the Board to assess and triangulate data to identify any areas of concern or strengthen the assurance received..2.2 This report (called the Integrated Performance Report or IPR) incorporates a mix of KPIs including the various elements of the Trust s performance management framework i.e. quality, activity, finance, workforce and risk. These KPIs are tied into strategic aims, annual corporate objectives and quality priorities..3 Structure.3.1 The committee structure supports the organisation by taking individual components of the performance management framework and scrutinising them in more detail. Any concerns are escalated upwards through the committee structure in the Chair s Reports..4 Assignment of Monitoring Function to a.4.1 The Board may assign the monitoring of particular performance indicator(s) to a committee. Where the Board assigns the monitoring of performance indicators, the Board will be explicit concerning the conditions for escalation back to the senior committee / Board. West London Mental Health NHS Trust Page 9 of 13

10 .4.2 The Board may elect to monitor a KPI itself but to assign the monitoring of a related action / escalation / recovery plan to a committee. The Board will be explicit concerning the conditions for the escalation of the issues back to the senior committee / Board e.g. deterioration / variation of RAG rating (from green to amber / amber to red).5 Operational Performance Management.5.1 CSUs and corporate departments will cascade performance management down throughout the organisation on a monthly basis. Quarterly performance meetings with members of the executive team review performance at CSU / corporate level and escalate any concerns to the Trust Management Team.. Action Plans..1 Where the Trust has identified a problem, it will assign key roles and responsibilities to ensure the issues are effectively addressed in a timely manner. In delegating the action, the Board will outline reporting requirements in order to maintain an auditable overview of progress..7 The Council of Governors.7.1 A key statutory role for the Council of Governors is to hold the Board of Directors collectively to account for the performance of a NHS foundation trust, including ensuring the Board of Directors acts so that the NHS Foundation Trust does not breach the terms of its authorisation e.g. The Trust shall put and keep in place and comply with arrangements for the purpose of monitoring and improving the quality of health care provided by and for the Trust..7.2 Governors will represent the FT membership (and in case of the appointed governors, the broader public) and may raise any concerns identified through their regular engagement with members. 7. TRAINING There is no mandatory training necessary / available on the requirements of this policy. Staff are expected to familiarise themselves with the policy contents. 8. FRAUD STATEMENT Not applicable to this policy. 9. REFERENCES (EXTERNAL DOCUMENTS) Beer, M., Eisenstat, RA (2004) How to Have an Honest Conversation About Your Business Strategy. Harvard Business Review. Being Open: NPSA 10. SUPPORTING DOCUMENTS (TRUST DOCUMENTS) Risk Management Strategy Risk Management Policy (R1) Supervision Policy (S2) Whistleblowing Policy (W1) Being Open Policy (O2) Incident Reporting and Management Policy (I8) Safeguarding Adults Policy (S28) West London Mental Health NHS Trust Page 10 of 13

11 Safeguarding Children Policy (C18) Dignity at Work Policy (B3) Patient Advice and Liaison Policy (P9) Management of Complaints, Concerns, Compliments & Suggestions Policy (C1) Clinical Audit (C28) 11. GLOSSARY OF TERMS / ACRONYMS BAF CQC CQUIN CCG CSU DARG FT GP HR IPR KPIs LATs MHA NTDA NHSLA PALS PbR PDR RAG rating SMT TDA Board Assurance Framework Care Quality Commission Commissioning for Quality & Innovation Clinical Commissioning Group Clinical Service Unit Data Assurance Review Group Foundation Trust General Practitioner Human Resource Integrated Performance Report Key Performance Indicators Local Area Teams Mental Health Act NHS Trust Development Authority NHS Litigation Authority Patients Advice and Liaison Service Payment by Results Personal Development Review using Red Amber Green as a way of rating seriousness or urgency etc Senior Management Team Trust Development Agency 12. APPENDICES. Appendix A: Governance Structure Appendix B: Monitoring Template West London Mental Health NHS Trust Page 11 of 13

12 Appendix A: FT Programme Board MHA Managers St Bernard's Redevelopment Programme Board Broadmoor Redevelopment Programme Board Trust Board Service User & Carer Forum Charitable Funds Local Services' Transformation Board Remuneration & Nominations Staff Engagement Property & Land Sales Trust Management Team Audit Finance & Investment Quality Assurance Trust Partnership Forum Capital & Asset Planning Management Group Informatics Sub Clinical Effectiveness & Compliance Sub CSU Senior Management Team Meetings Estates Liaison Trust Records & Information Governance Patient Safety & Safeguarding Sub CSU (& Support Services') Integrated Performance Meetings Recovery Programme Board IG, Security & Caldicott Clinical Technology Oversight Business Technology Oversight Service User & Carer Experience Group Research & Development Sub- Medical Education Data Reporting & Assurance Oversight Key Chaired by Non Executive Chaired by Executive West London Mental Health NHS Trust Page 12 of 13

13 APPENDIX B POLICY / PROCEDURE: E7 Escalation Policy MONITORING TEMPLATE Minimum Requirement to be Monitored Where Described in the Policy WHO (which staff / team / dept) HOW MONITORED (Audit / process / report / scorecard) - list details HOW MANY RECORDS (No of records / % records) FREQUENCY (monthly / quarterly / annual) REVIEW GROUP (which meeting / committee) OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Concerns escalated upwards.3 Board Sub s Via Chairs reports 100% Monthly / bi monthly QAC / TMT / F&I Board West London Mental Health NHS Trust Page 13 of 13