Revisions to the governance and committee structures will be updated in line with approvals at the December Trust Board.

Transcription

1 REPORT TO THE TRUST BOARD - 19 th DECEMBER 2013 Title Board Assurance and Escalation Framework N Executive summary The Board Assurance and Escalation Framework (BAEF) describes the Trust s quality governance structure and systems through which the Trust Board receives assurance. It also describes the process for the escalation of concerns or risks which could threaten the delivery of the Trust s strategic objectives, service delivery or patient safety. A number of key areas have been described within this document for clarity. This Framework is intended to be a dynamic process that will be reviewed on an annual basis in order to reflect any changes in governance, assurance and escalation processes. The BAEF has undergone extensive consultation via the Quality Assurance Committee, has been subject to prior Trust Board consideration through a Board Development session, and has been presented to the Audit and Assurance Committee. Following on from the consultation period the BAEF is presented as an updated framework with the following additional and updated sections: Risk assurance and risk escalation (greater emphasis on QAC s role) Assurance sources (wider explanation of Clinical and Internal Audit linkages to the risk management framework) Patient and Public Involvement (updated) Cost Improvement Plans (updated) External Visits and Recommendations (new section) External intelligence and horizon scanning (new section) Reputational Risk Analysis (new section) Revisions to the governance and committee structures will be updated in line with approvals at the December Trust Board. Recommendation The Trust Board is recommended to: Adopt the Board Assurance and Escalation Framework

2 Related Trust objectives Risk and assurance Legal implications/ regulatory requirements Evidence for the Quality Governance Framework (eg paper evidences board engagement with staff (3C) Presenting Director Author(s) We will continuously improve quality and safety, with services shaped from user experience, audit and research. Local Risk 140. Corporate Risk 909. Continued effective Risk Management is critical to the achievement of the IBP Strategic Objectives, the Board Assurance and Escalation Framework demonstrates and ensures effective ward to board escalation processes. Nil to note 1B Is the board sufficiently aware of potential risks to quality? 3B Are there clearly defined, well understood processes for escalating and resolving issues and managing quality performance? Adrian Childs, Chief Nurse Richard Apps, Head of Risk Assurance *Disclaimer: This report is submitted to the Trust Board for amendment or approval as appropriate. It should not be regarded or published as Trust Policy until it is formally agreed at the Board meeting, which the press and public are entitled to attend

3 Board Assurance and Escalation Framework

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5 Contents 1. Introduction Purpose Background to Quality Improvement Quality Improvement Framework Organisation Committee Structure Key assurance systems and processes Patients, Carers and Public Involvement Staff Involvement Key Stakeholder Engagement Internal Performance Monitoring Monitoring Compliance with Care Quality Commission Essential Standards Risk and Risk Escalation Trust Assurance Framework Risk Registers Local and Service Risk Registers Divisional Risk Registers Corporate Risk Register Serious Incidents Assuring Board Effectiveness Cost Improvement Plans (CIPs) Data Quality Learning Lessons Reputational Risk Analysis External Visits and Recommendations External intelligence and horizon scanning Internal and External Sources of Assessment and Assurance Clinical Audit Internal Audit Escalation of Risks Outside of Committee Structure Conclusion Appendix A Trust Assurance Framework Appendix B Responsibilities of Board Committees... 24

6 a. Audit & Assurance Committee b. Remuneration Committee c. Workforce and Organisational Development Committee (WOD) d. Finance and Performance Committee (FPC) e. Quality Assurance Committee (QAC) f. Charitable Funds Committee Appendix C Reportable Issues Log... 25

7 1. Introduction 1.1. The Trust has developed and implemented a range of policies, procedures, systems and processes in order to assure the Trust Board that governance, quality and risk issues are appropriately managed. These provide the Trust with a robust assurance and escalation framework The assurance and escalation framework demonstrates how the Trust s quality and risk systems, and learning from quality data is monitored by an effective committee structure and links to Monitor s Quality Governance arrangements and the Care Quality Commission s requirements for registration. This provides the Trust Board with assurance about how the organisation is able to identify, monitor, escalate and manage concerns in a timely fashion at an appropriate level. 2. Purpose 2.1. This Framework describes the Trust s quality governance structure and systems through which the Trust Board receives assurance. It also describes the process for the escalation of concerns or risks which could threaten the delivery of the Trust s strategic objectives, service delivery or patient safety. A number of key areas have been described within this document for clarity This Framework is intended to be a dynamic process that will be reviewed on an annual basis in order to reflect any changes in governance, assurance and escalation processes The BAEF is comprised of three key Components: A summary of the key assurance systems and processes in place for; Patient and Carer Involvement staff involvement Key Stakeholders (Commissioners and Partners) Performance Monitoring CQC Compliance Risk Management and Escalation Serious Incidents Board Effectiveness Quality Impact of CIP Schemes Data Quality Learning and Implementing Lessons Reputational Risk Analysis External Visits and Recommendations External intelligence and horizon scanning Describes the roles and accountabilities of committee structures in place in support of Board assurance Page 7 of 25

8 The Reportable Issues Log presented to Trust Board once a month this concise report highlights key issues and risks, identifies a lead director and details progress with mitigating actions. 3. Background to Quality Improvement 3.1. This Board Assurance and Escalation Framework is designed to support the delivery of the strategic objectives of the organisation. Our service users, carers and families deserve the highest quality of care we are able to provide and as the NHS moves through its reform agenda, maintaining and improving quality is becoming increasingly more important. We know that our service users expect us to do the right thing and to do the thing right From a national perspective a number of initiatives have been introduced to improve the quality of care NHS Trusts provide. These initiatives include a standard mental health contract, Commissioning for Quality and Innovation (CQUIN), Quality Accounts and Quality, Innovation, Productivity and Prevention (QIPP). These are intended to improve the outcomes for service users by linking quality improvement to the contracting process and rewarding organisations for delivery of those improvements. Each trust must be publicly accountable for declaring how it has assured itself about the quality of its services and what the future priorities are for delivering quality improvement Previous reports by the Department of Health (2008) state that quality should be at the heart of the NHS and the services trusts provide. It has also suggested that three areas should be focussed upon: Patient experience Effectiveness Safety 3.4. The Kings Fund, in conjunction with the Burdett Trust for Nursing, produced a report entitled Putting Quality First in the Boardroom Improving the Business of Caring (2010) The report focuses on the rising clinical quality agenda, in particular the role of nurse executives, but clearly identifies ways in which Trusts can work in ensuring quality is a key part of the business considered within the boardroom In July 2010, Equity and Excellence: Liberating the NHS was launched. This document set out a vision for an NHS configured to deliver increasing quality of services and made clear that patients should be in the lead in the healthcare system empowered by information and choice. This vision puts patients and the public first increasing choice and enabling patients to rate hospital and clinical departments according to the quality of care they receive. Healthcare outcomes will therefore be improved and the NHS will be held to account against clinically credible and evidence based outcome measures, with quality standards informing commissioning and providers being paid according to performance. The vision is critical in continuing to protect and improve patient safety and to plan and implement the required improvements in quality and productivity. Page 8 of 25

9 4. Quality Improvement Framework 4.1. The Trust s approach to developing its strategy and business planning has based itself on the premise that it aims to put quality at the heart of all services and ensure that it is able to demonstrate its contribution to the national quality improvement framework. It has reflected on the best available evidence for ensuring quality is a significant driver within the organisation and as such it has adopted the three pillars identified by the Department of Health (2008) Figure 1. Quality Improvement Framework PERSON CENTRED A passion for quality & excellence EFFECTIVE SAFE 5. Organisation Committee Structure 5.1. The Trust s strategic plan is implemented, monitored and assured by the committee structure which has delegated responsibility from the Trust Board. The committee structure monitors compliance through performance indicators, a comprehensive audit programme, the monitoring of associated risks and through other mechanisms of assurance. The table below demonstrates the reporting and accountability mechanisms (i.e. groups report to committees, committees report to Board committees and Board committees report to the Trust Board). These are supported by clear Terms of Reference (ToR), the committee structure is shown in Appendix A and responsibilities are described in Appendix B. Page 9 of 25

10 6. Key assurance systems and processes 6.1. Patients, Carers and Public Involvement The Trust Board has approved a Service User Strategy and Carer Strategy that directs the development of our engagement and involvement with service users and carers. This strategy was co-produced with patients and carers and covers all aspects of the services provided by the Trust The Trust encourages patients and/or their carers and the public to make comments, share their experiences and/or raise concerns both formally and informally via a number of mechanisms. These include:- Customer Services incorporating a Patient Advice and Liaison Service (PALS) and complaints service both formal and informal Patient experience questionnaires including privacy and dignity, and the development of entry and exit questionnaires. Patient Stories presented at Trust Board Regular feedback and meetings with Healthwatch Local Authority Health Overview and Scrutiny Committee, Section 75 Partnership Board Development of a Trust wide Patient and Carer Reference Group Divisional VCS partnership working. For example the Adult mental health service has been supported in the development of a VCS forum specific to Adult Mental Health. This will provide VCS organisations with a direct communication route to discuss concerns or ideas with the Divisional Lead and heads of services. Service User led Ward Forums in Adult MH Localised meetings with service users and carers an example of this is the In Your Shoes programme where staff and patients/carers can talk one to one about what it is like to use our services Leadership walks Inclusion of service users and carers in Trust work including Recruitment Friends and Family Test the Trust is an early adopter of the FFT in mental health and community health and also in prison health care. Patient Reported Experience Measures (PREM) as part of the development of Payment by Results, this pilot work enables the Trust to look at service user experience along a particular mental health pathway. Page 10 of 25

11 6.2. Staff Involvement The Trust has a number of policies and systems which encourage staff at all levels to involve them in performance monitoring and to raise concerns about any quality and risk issues. These include:- Public Interest Disclosure Act - Whistleblowing policy Human Resource policies and procedures National staff surveys Safeguarding policies and procedures Staff Pulse Survey (3 per year) Local trust quarterly pulse surveys Risk Management Strategy Risk Management Policy Incident and Serious Untoward Incident policy Care Quality Commission compliance with registration outcomes (including self-assessments) Exit Questionnaires Information Governance policies and processes HOG Healthy Organisation Group Monthly meetings with staff side at a divisional level and every 2 months at an organisational level 6.3. Key Stakeholder Engagement In addition to the internal routes for raising concerns and risk, there are formal mechanisms by which our key stakeholders can raise concerns. These include:- Regular contract and performance review meetings with our commissioners Regular quality review meetings with our commissioners CQUIN review meetings with our commissioners Regular meetings with the Clinical Commissioning Groups Attendance at the Mental Health Clinical Board Incident and Serious Untoward Incident process Complaints process Specialist commissioning meetings. Regular meetings with the NHS Trust Development Authority 6.4. Internal Performance Monitoring The Trust has a number of meetings where performance is monitored. The key performance meetings consider performance against key performance indicators, financial performance, workforce metrics and quality metrics. These include:- Trust Board Page 11 of 25

12 Divisional Executive Performance Reviews Quality Assurance Committee Finance and Performance Committee Workforce and OD Committee The Trust Board and it s Committees receive an Integrated Quality and Performance Report (IQPR) each month that considers performance against key operational targets and quality performance metrics. Performance is RAG rated and includes exception reports. Where adverse performance is noted, narrative is provided by the responsible Director and where necessary separate papers are provided. The Finance and Performance Committee receives a separate paper each month that details performance and risk regarding financial activity and the financial status of the organisation Performance is managed at a local level through monthly Divisional Management Team (DMT) meetings. Each Division considers its performance against key performance targets and reviews the performance of individual teams within the Division against these indicators. Outlying teams are identified and actions implemented to address the performance issue Monitoring Compliance with Care Quality Commission Essential Standards The Trust has a system in place to enable services to escalate risks of noncompliance with the CQC Essential standards of quality and safety. Team leaders, use peer review to triangulate evidence to determine if there are any risks of non-compliance which are then escalated on to the risk register. Each CQC Outcome has a corporate nominated lead whose role it is to consider whether there are themes and trends across multiple services to ensure the effectiveness of their strategies Risk and Risk Escalation Trust Assurance Framework In August 2013 the Trust introduced a revised Risk Management Strategy. This included revised committee responsibility structure and the development of a system and process for escalating where necessary local risk registers to a Corporate Risk Register (CRR) The Trust manages quality governance and risk through the Trust Assurance Framework. However, in order to ensure the Trust Board is fully conversant with all risks as they occur, it also receives a reportable issues log. This log is compiled on a monthly basis and considered during Page 12 of 25

13 the closed session of the Trust Board. The log reports all Serious Incidents as they occur, complaints, claims, Section 28 Letters and employment tribunals. (Appendix C) Risk Registers As part of the Trust Assurance Framework, the Trust produces risk registers at a Local, Service, Divisional and Corporate level The risk registers are recorded using a standard risk assessment template each risk is rated according to the impact/likelihood risk assessment matrix identified within the Trust s Risk Management Strategy. This is based on international guidance and best practice. The Risk Registers identify:- The risk to achieving the local, service, divisional or strategic objectives. The current risk rating for each risk (at the point of risk assessment) The risk owner The controls that are in place to assist in securing delivery of the objective. The assurances that enable evidence to be gained that our controls are effective The actions that are being taken to reduce the risk. The residual risk rating (the predicted risk rating when the planned actions are in place) Local and Service Risk Registers Each inpatient ward team and community team is able to produce a local risk register. The register is developed in response to the identification of local risks that may impact on the delivery of their immediate service. Local risk registers are recorded using the standard Trust template within the electronic risk management system All local risk registers are systematically reviewed by the monthly Divisional Governance meeting. Risk escalation occurs from initial level once it is established that current and planned mitigation cannot reduce the level of risk exposure below a tolerable level; in practical terms this means that if residual risk is scored above 8 at amber or red (see figure 2) the risk should be escalated, re-assessed, managed, and if appropriate (residual risk remains amber or red) escalated once more etc. Conversely risks should be de-escalated once residual risk, through additional current or planned mitigation has demonstrated suitable risk reduction, i.e. a residual risk of green or yellow (see figure 2) has been achieved. Page 13 of 25

14 Figure 2. Risk Management Strategy line of tolerance Divisional Risk Registers Each Division produces a risk register. This register is developed in response to risks identified through incidents, serious untoward incidents, complaints and risks to achieving the annual objectives which are derived from the organisations strategic objectives. They also incorporate any risks identified at a local and service level with a residual risk score of 8 or above (amber or red) escalated as described above. The Divisional Risk Registers are reviewed in the Divisional Governance meetings Divisional Risk Registers are reviewed at the Executive Performance Review Meetings. Divisional risks with a residual risk of amber or red are referred to the Quality Assurance Committee for consideration of inclusion on the Corporate Risk Register Corporate Risk Register The Corporate Risk Register is the aggregation of the local risk registers through the escalation processes described above and the inclusion of any further risks identified by the Directors, Quality Assurance Committee and Trust Board in achieving the Trust s strategic objectives. Each risk on the Corporate Risk Register identifies a risk owner (lead Director) for managing the risk. The register identifies the actions being taken to mitigate the risk, including controls and assurances. All risks are linked to one of the Trust s strategic objectives and the Register is reviewed on a monthly basis by the Quality Assurance Committee The Quality Assurance Committee will receive and consider notification of potential risks and assurances arising out of clinical audit activity via the Senior Clinical Quality Group. Similarly risks and assurances arising from internal audit activity will be highlighted to the Quality Assurance Committee by the Audit and Assurance Committee. Page 14 of 25

15 6.7. Serious Incidents The Trust has a system and process in place to manage all Incidents and Serious Incidents Safeguard is a web based service and training is provided to staff to enable them to report all incidents accurately. Training includes basic usage of the system and any programme updates that impact on staff using the system All incidents are reported through the electronic Safeguard system which provides the incident with a harm rating. Incidents meeting potential SI criteria require a 72 hour report to be completed. Following completion of this report it is reviewed by the Patient Safety Lead and a decision is made as to whether a formal review should be undertaken All SI reviews are considered by the Quality Assurance Committee along with the associated action plan to implement any recommendations The Quality Assurance Committee receive a quarterly report on SUIs that have occurred and themes and trends for learning are identified All SIs are reported to the Trust Board on a monthly basis through the reportable issues log. Appendix C The Trust Lead for Patient Safety will provide an annual report to the Quality Assurance Committee which identifies the number of incidents which have been overseen by the SI process and the key themes identified throughout the year and action taken in response Assuring Board Effectiveness There are a number of ways in which the Trust Board assures itself that it is fulfilling its duties effectively. These include:- Self-assessments External effectiveness reviews Annual assessment against Board Governance Assurance Regular informal Trust Boards Regular Trust Board workshops Quality Assurance of Trust Board minutes Maintenance and robust follow up of action log Robust non-executive director induction Non-executive director supervision Executive director supervision Page 15 of 25

16 6.9. Cost Improvement Plans (CIPs) The value of the Trusts overall CIP requirement is determined through the financial planning process and is set at a level that will ensure delivery of the Trusts statutory financial duties and any supplementary targets required by the TDA and to ensure financial sustainability in the medium term The Trusts Transformation and CIP Group (T&CG) develops the scope and content of a Trust-wide CIP programme and the priority areas for consideration. The T&CG aims to develop an outline CIP programme that exceeds the Trust CIP requirement by 25% to allow for the risk of abortive schemes and nondelivery In the context of the T&CG outline CIP programme, individual schemes are allocated a lead director and a lead manager to develop a detailed Cost Improvement Plan. CIP leads complete a CIP planning and monitoring template that sets out the detail of each scheme and includes an overall quality assessment, and a separate assessment to evaluate the risk to service quality and safety. Details of any mitigating actions are also included. Each CIP template states the KPI metrics or markers to be used for both finance and quality impacts with a focus on post implementation measurement and any quality impact which might be felt in other parts of the Trust Individual CIPs plans are scrutinised by the Transformation & CIP Group to assess viability. Schemes approved for delivery are formally signed off by the Director of Finance with respect to financial viability, and by the Medical Director and Chief Nurse with respect to service quality and safety As part of the quality and safety assurance processes, details of all CIP schemes impacting on clinical services will be shared with Commissioners, and any concerns expressed by Commissioners will be resolved prior to scheme delivery CIP delivery is managed through Divisional SMTs, with Divisional performance monitored through the Executive Performance Reviews on a monthly basis. Delivery of the financial targets for each CIP is also riskassessed and RAG rated and summarised within the monthly finance report to FPC and the Trust Board If at any point during planning or delivery a CIP scheme is assessed as having a RED rated risk to quality or safety, the specific CIP scheme will be reviewed by the T&CG, and if necessary escalated to the Executive Team. If risks cannot be mitigated or otherwise managed or reduced, the scheme will not be approved for delivery, or if in process of delivery - will be suspended. Page 16 of 25

17 6.10. Data Quality The Trust has a legal responsibility to ensure that its data is accurate and up to date to comply with the Data Protection Act Healthcare professionals have a duty through their professional codes of practice to make accurate records of the care they provide The Trust must adhere to the data standards outlined in the NHS Data Dictionary and associated Data Set Change Notices (DSCNs). These standards ensure that data sets are consistent across the NHS, thus allowing comparisons at a national level The Trust is required to meet the standards outlined in the Information Governance Toolkit The Trust ensures sustainability and improvement of Data Quality through operationally monitoring different elements of good practice including timeliness, source and validation Information staff provide regular reports and self-service reporting facilities to all staff groups to enable them to monitor their own data quality and correct errors or omissions in existing data. These reports are also used to inform management, to improve procedures and documentation, and to identify training needs Information on data quality within individual teams, services and localities is provided on a regular basis and forms part of the regular local performance monitoring process Learning Lessons The Trust is committed to learning lessons in an open and transparent way. It does this through the examination of complaints, incidents, serious incidents, staff feedback, patient feedback, internal reports, external reviews, assessments and inspections and the review of national reports and reviews. This is achieved in a number of ways:- Trust Board reviews Quality Assurance Committee reviews Triangulated reports to consider themes and trends Clinical Governance Committee reviews Review of SI reports by Directors and commissioners SI report feedback by senior managers to teams involved Senior leadership Group Senior Management Team Targeted training and development Direct team and individual feedback Operational Management Team meetings Trust communications Patient safety group Page 17 of 25

18 Action plans and recommendations are monitored through local clinical governance meetings Reputational Risk Analysis The communications team is responsible for the Trust s media handling policy which aims to both protect and enhance the Trust s reputation. A risks and reputation log is prepared regularly for the executive team The communications team log potential media issues as well as the risk owner and the mitigations (usually a media handling plan or statement as well as an identified spokesperson). This is then tabled on a biweekly basis with the executive team with new risk and current fortnight risks being discussed. The log itself is updated as new risks come in by communication team members and at any time should be completely up to date External Visits and Recommendations The Quality Assurance Committee is the Committee with overarching responsibility for management of all visits. The QAC: Is the designated committee for monitoring compliance and outcomes Receives a monthly summary report of all visits in order to be assured through action plans that any recommendations made are addressed, and a 6 monthly step back review of the totality of the visits over the report period Reports through to Board on immediate issues raised through the monthly Board Highlight report Reports on general progress or areas of concern arising from visits The Director of Corporate Affairs is the Corporate Lead for all visits. Key responsibilities are to: Ensure a log of visit report proformas and action plans (if required) are maintained on a centrally held record Provide periodical reports of results of visits to the QAC Inform the Board and Commissioners at the earliest opportunity of unannounced Care Quality Commission visits, and all notified visits from external agencies Page 18 of 25

19 6.14. External intelligence and horizon scanning The Business Development Team is responsible for the Trust s external intelligence and horizon scanning process which aims to ensure that the organisation is fully sighted on the external environment and its influence and impact on the Trust s current and future business The team s Market Analyst (currently under recruitment) will work with the wider Business Development Team, operational and strategic managers across service and enabling divisions and through external links to gather key information and develop a comprehensive picture of the Trust s external market, new and repeat business opportunities and internal and external reputation Internal and external intelligence and the Trust s market assessment are considered at the Business Development Group on a monthly and quarterly basis respectively with action taken in line with the information shared Internal and External Sources of Assessment and Assurance Internal Integrated Quality and Performance Report (IQPR) Divisional Performance Scorecards / Executive Performance Reviews (EPR) Key Performance Indicators Reportable Issues log Minutes Committee Reports Divisional Governance Reports Divisional and Service Level Risk Registers Quality Accounts Internal Audit Reports Head of Internal Audit opinion Local Counter Fraud Reports Staff Survey Results Complaints / compliments reports PLACE Inspections Serious Untoward Incidents Investigations Clinical Audit Clinical Presentations External assessments, reviews and benchmarking Care Quality Commission visits/ inspections NHS Litigation Authority assessments National Audits (e.g., suicide) Reviews of external independent reports Quality Accounts Quality Risk Profile Health and Safety Inspections External Audit Reports Annual Audit Letter National Staff Surveys NHSLA Reports National Patient Satisfaction Surveys National staff surveys National Patient surveys Page 19 of 25

20 Internal Quality Visits Service level dashboards CQC Compliance Visits External assessments, reviews and benchmarking Clinical Audit At the start of the financial year the SCQG approve an annual clinical audit forward plan of priority clinical audit activity for the Trust. This takes account of national, regional and local requirements. The National Healthcare Quality Improvement Partnership Clinical Audit Programme Guidance tool (HQIP, 2009) is used to prioritise audits The tool consists of four levels: Priority level one External must do audits Priority level two Internal must do audits Priority level three Divisional priorities Priority level four Clinician interest The Medical Director will provide clarity regarding the priority levels of audits when required The LPT clinical audit forward plan consists of priority level one and two audits. Prior to commencing level one and two audits, Clinical Audit leads must have proposal forms approved by the relevant subgroup of the QAC. The Clinical Audit Officers will support Clinical Audit Leads to facilitate the delivery of these audits. The appropriate sub-group of QAC is required to approve proposals as they arise throughout the year The Clinical Audit Plan is triangulated against the risk register during the year to ensure congruency of risk entries and completeness of assurances arising from clinical audits Internal Audit Conceived at the start of each financial year the internal audit forward plan seeks to ensure the strategic risks identified within the Trust are subject to adequate testing and review; The Internal Audit forward plan is predicated on the strategic risks identified within the Board Assurance Framework, has input from Board Directors, and is reviewed in detail by the Audit and Assurance Page 20 of 25

21 Committee NED members in a workshop prior to formal approval at the Audit and Assurance Committee Executive Directors flag-up additional concerns, issues and emerging risks throughout the lifecycle of the plan. Where appropriate these are incorporated into the internal audit plan Non-Executive Directors at the Audit and Assurance Committee may identify necessary deviation and addition to the plan, with support from internal auditors The forward plan is revisited periodically throughout the year for completeness The Internal Audit Plan is triangulated against the risk register during the year to ensure congruency of risk entries and completeness of assurances arising from internal audits The Trust also commissions external reviews of activities, services and events where a need for additional independent assessment and assurance has been identified Escalation of Risks Outside of Committee Structure Risks and issues that are identified outside of the committee structure are reported to the Trust Board on a monthly basis through the reportable issues log. Where possible these will be fed into the committee structure and dealt with in the normal way. Where this is not the case, the reportable issues log identifies the issue description, the lead director and the action being undertaken, (Appendix C) Triggers that identify reportable issues include:- Incident reports Serious Incidents Coroner Communications Regulation 28 letters Claims Red Rated Complaints Employment tribunals Care Quality Commission notifications NHS Litigation Authority notifications Notifications from professional bodies Notifications from local commissioners Notifications from Monitor Identified Reputational Risks Any issue identified through the course of the organisations daily business that poses a significant threat to the Trust and its ability to deliver services is considered by the Chief Executive and Chairman of the Trust. The Chief Executive, or nominated Director, will ensure the Trust Secretary informs all Page 21 of 25

22 Directors and Non-Executive Directors immediately of the issue and the risks posed to the Trust. 7. Conclusion 7.1. The Board Assurance and Escalation Framework will be reviewed on an annual basis by the Trust Board. To ensure it is effectively utilised the Quality Assurance Committee will retain oversight of its implementation through its regular work plan, review of issues escalated to it and the review of risk registers. Page 22 of 25

23 Appendix A Trust Assurance Framework Page 23 of 25

24 Appendix B Responsibilities of Board Committees a. Audit & Assurance Committee The purpose of this Committee is to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the organisation s activities (both clinical and non-clinical) that supports the achievement of the organisation s objectives. b. Remuneration Committee The purpose of this Committee is to ensure that there is a fair and transparent procedure for developing and maintaining policy on executive remuneration and for fixing the remuneration packages of individual directors. c. Workforce and Organisational Development Committee (WOD) The purpose of this Committee is to steer and monitor the Trust s Workforce and Organisational Development strategies and plans and to provide the Trust Board with assurance on Workforce key performance indicators and deliverables. d. Finance and Performance Committee (FPC) The purpose of the Committee is to provide the Trust Board with assurance on the development and delivery of financial strategies and achievement of key financial indicators; also to review and provide assurance on business development and investment, and to ensure the delivery of key performance indicators, including contractual performance targets. e. Quality Assurance Committee (QAC) The purpose of this Committee is to monitor the Trust s Quality strategies and plans and to provide the Trust Board with assurance on risk management, Quality Key Performance Indicators (KPIs) and deliverables. f. Charitable Funds Committee The purpose of this Committee is to manage, on behalf of the Trust Board and in accordance with Standing Orders, charitable funds held; also to provide assurance to the Trust Board on the effective management thereof. Page 24 of 25

25 Appendix C Reportable Issues Log REPORTABLE ISSUES LOG Date: Date Added Issue Type Date of Occurrence Division/ Service Issue Description Lead Director Progress Update Page 25 of 25