The Royal Wolverhampton NHS Trust

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1 The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 2 June 2014 Title: Board Assurance Committee / Quality Governance Assurance Committee Annual Summary Report /2014 Executive Summary: Action Requested: Report of: Author: Contact Details: Rosi Edwards For Information Only Board Assurance Committee / Quality Governance Assurance Committee Annual Summary Report /2014 Rosi Edwards Tel gayle.nightingale@nhs.net Resource Implications: Public or Private: (with reasons if private) Public Session References: (eg from/to other committees) Appendices/ References/ Background Reading NHS Constitution: (How it impacts on any decision-making) In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny Background Details 1 This report was presented to and accepted by the joint Audit/Quality Governance Assurance Committee meeting on 23 April without amendment. The new committee and Group structure has been developing over the year and were now functioning well, in line with the expectations of the Price Waterhouse Cooper report on Trust Governance. Two NEDs on QGAC have attended the two key Groups, Quality Standards Action Group and Patient Safety Improvement Group respectively and received reports from the groups which feed into these. In reviews of the meetings a need had been identified for improved reports which made it clear what the significant issues were, good or bad, and what was being done about them. Governance had provided training and briefing and had developed a report template and

2 provided a short explaining in simple terms what the Committee needed and why. This is leading to improved reports and enabling QGAC to offer assurance to the Board, resulting in shorter more focussed Board meetings. QGAC is also overseeing the development of a more focussed Board Assurance Framework and Risk Register, based on the recommendations of Internal Audit. THE ROYAL WOLVERHAMPTON NHS Page 2 of 8

3 BOARD ASSURANCE / QUALITY GOVERNANCE ASSURANCE COMMITTEE ANNUAL SUMMARY REPORT /2014 Non-Executive Director Chairman April Purpose of the Board Assurance/Quality Governance Assurance Committee The Trust has established a committee to assure the Board of the effective functioning of risk management systems through a reporting framework that reviews care standards/targets, monitors quality and safety performance and escalates as appropriate to the Board. This report informs on the work activities undertaken by the committee in /2014 and future work development in 2014/2015. Page 3 of 8

4 1.1 Board Assurance arrangements in /2014 Within the reporting year period 13/14 the Trust underwent an independent review of its Governance arrangements (conducted by Price Waterhouse Cooper (PwC)) and received recommendations affecting its committee structure and reporting arrangements that were implemented later in the year. This report will therefore present the work of the Assurance committee pre and post the review recommendations. The Trust Integrated Governance strategy contains the assurance framework arrangements for the Trust and is reviewed annually. Due to the PwC review and significant changes recommended to the governance arrangements it was agreed to carry forward the 12/13 strategy for 13/14 to allow adequate time to implement all actions. The changes/actions described in this report will be reflected in the 14/15 review of the strategy. 1.2 Work Activity /2014 The PwC review led to changes in the Committee and reporting structure for the Trust. The former Board Assurance Committee was replaced by a Quality Governance Assurance Committee (QGAC) (henceforth referred to as the Committee) with revised terms of reference scope and membership. Between April and August the Committee met every two months and monthly thereafter. The terms of reference for subgroups and specialist groups reporting to the Committee were reviewed and expanded where necessary to ensure that appropriate report information was received to inform assurance. Each group was asked to identify key output areas for upward reporting. A schedule of reports to the Committee was agreed for the year consisting of subgroup reports, performance and compliance reports; as well as themed reviews on subjects which Committee members believed would indicate risk /assurance intelligence. To enhance the content of upward reports made through the framework, report templates were created to direct the focus on performance indicator monitoring, positive/negative assurance against standards and residual risk/actions. The template and reporting workshops established have shown notable improvements in the summary and emphasis of reports produced. The Committee reviews chairman reports and subgroup minutes at each meeting and members raise questions or challenge arising from these. The Committee provides a Chairman report and minutes to the Trust board following each meeting, drawing from risks and/or assurances reported. A standing agenda item exists to extract issues for escalation for Trust Board. Further developments to refine Trust Board reporting are planned for 14/15 (see section 1.4 below). The Committee approved an Assurance and Escalation Framework in October which described the levels of information and reporting through the Committee structure and linkages with risk registers and independent assurance. The Committee and its subgroups introduced a standing agenda item for evaluating each meeting. This item considers the general conduct of the meeting including reports produced, presentation made and whether the meeting achieved the intended outcome (i.e. Terms of Reference). An example of an area addressed through meeting evaluation was to improve the quality and content of reports received. To this end a guided template was produced and is now well used, reporting workshops were provided and a standard to report authors explaining requirements. Page 4 of 8

5 Follow up evaluation from members shows a notable improvement in reports produced. This development in reporting was requested for sharing at a meeting for Non Executive Directors from aspirant foundation trust on effective board challenge run by the Foundation Trust Network in April 14. The Committee maintains links with the Audit Committee through a standing agenda item ( issues of significance from Audit Committee ) which ensures a two way feed of information between the committees. There is also an overlap in terms of attendance by a non-executive director to both committees. The Committee considered various matters during the year including: The Board Assurance Framework and Trust Risk Register Integrated Quality and Performance report Safeguarding Assurance report NICE and National guidance assurance report Care Quality Commission regulatory Compliance Litigation and Inquests report Clinical Audit report Hospital Mortality Subgroup reports/minutes In addition the Committee reviewed the Annual Governance Statement for 2012/13 at a joint meeting with the Audit Committee in April (alongside the opinion of the Head of Internal Audit to triangulate assurance). To inform the Committee, the sub groups reporting to it have conducted detailed reviews of compliance and risk status on the following key areas: Compliance with the use of the safer surgical checklist Policy audit reports e.g. Transfer, Discharge, Risk management and integrated Governance strategy, Being open, Complaints, Legal services Safety alert compliance e.g. NPSA, MHRA, MDA SUI management (process, investigation outcomes and action tracking) Essential Standards for Quality and Safety (ESQS) and Registration Compliance National Clinical guidelines/standards e.g. NICE, NCE, Royal College reports National and Local audit performance for a number of clinical services External assessment and Validation for a number of clinical services Health and Safety Management Approval and review of new [clinical] procedure applications Overview of Risk registers Safeguarding performance Radiation protection Information Governance Organ Donation Medicines management Patient and Staff survey reports The non- exhaustive list above is factored into an annual plan of work for the Committee and its subgroups with upward reporting through chairman reports and minutes. NB. Reports above pertain to the Quality Standard Action group (QSAG) and the Patient Safety Improvement group (PSIG). The Academy steering group (which covers Education and Training for all staff) provides a 6 monthly report to the Quality Page 5 of 8

6 Governance Assurance Committee. It last presented a report in November and one is due in May 2014 and November Meeting attendance The audit of the Integrated Governance strategy showed overall good attendance and quoracy at the Committee with good Non executive representation (see appendix 1). Similarly the audit showed good overall attendance and quoracy at subgroup meetings (QSAG and PSIG). The Academy Steering group is newly established therefore attendance was not monitored in 13/14. Significant Quality Assurance events /14 The Care Quality Commission (CQC) carried out a planned (Keogh style) review in September, and identified 5 priority areas for improvement. An action plan is monitored by the Quality Standards Action group showing good progress. A re visit by CQC is overdue at the time of this report. The Trust achieved the highest level of compliance (level 3) with the NHS Litigation Authority risk management standards in September. This accreditation has provided independent positive assurance of the existence and operation of quality and safety systems for staff and patients. This result positively impacts the indemnity premium paid by the Trust and the litigation risk profile held for the Trust by the Litigation Authority. In real terms the result demonstrates that risk management is embedded in the organisation and there is ownership by front line staff, managers, and the organisation of the safety agenda. 1.3 Risk Registers and Board Assurance Framework During 13/14 the Trust maintained risk registers at 3 levels: Operational risk registers Division and Directorates Trust Risk Register (TRR) Operational risks escalated to Trust level under an Executive Director Board Assurance framework (BAF) Risks affecting the Trust Strategic objectives The Integrated Governance strategy directs that risk registers are to be reviewed at least quarterly and the Integrated Governance strategy audit showed 100% of Directorates held and reviewed risk registers at these intervals. There was a significant improvement in the timeliness of risk escalation to Trust level (TRR/BAF) and risks once escalated to BAF/TRR, were reviewed monthly by an Executive Director. There continues to be clear ownership of BAF/TRR risks by Executive Directors. The committee appropriately challenges the reasoning and progress that is made against these risks and update is provided to the Trust Board accompanied by the committee minutes. Independent assurance from the Trust internal auditors (Baker Tilly) for /14 concludes that the Trust Board can take reasonable assurance on the controls/system for management of the BAF/TRR. A number of new/revised risks were added to the BAF and TRR in 13/14 including staffing levels/establishment (risks 3685, 3431), CQC improvement areas (risk 3644), poor completion of the annual audit plan (risk 3370), Interventional radiology rota (risk 3494) Safeguarding impacts (risk 3353), impacts of Mid Staffs Service activity (risks 3645, 3330) and risk within Oncology (risks 3486, 943). Significant Page 6 of 8

7 improvement within year is shown in risk 2962 Health Visiting Business/systems/service, initially graded red on the BAF, it is now managed down to yellow. Risk 3256 re Premises at West Park Hospital (audiology) was managed and closed within year. Never Events have been retained on the BAF to further refine and monitor controls. In March 14 the Trust trialled and subsequently approved the use of a new format for the BAF. The format allows for closer monitoring of controls identified to manage risks, facilitates up to date results (i.e. positive/negative assurance) to be reported against controls and assigns a current risk status. Over time this will provide a clearer indication of the effectiveness of control measures in managing risk. This format will be progressed to the Trust Risk register in 14/15 with principles cascaded to local risk registers (i.e. Divisions and Directorates). 1.4 Assurance Priorities 2014/2015 Over the coming year the Trust will continue to progress enhancements to its internal assurance framework using all available intelligence. This work includes refinements in committee assurance reporting, mapping quality, performance and compliance data and development of new dashboards and granular reports to inform high level committees and the Board. Key to this work will be the identification of indicators to inform the committee and Trust Board on both positive and negative assurances. The Trust will develop Health Assure as an electronic solution to create a more live internal assurance repository for Quality and Safety information aligned to the CQC regulatory standards (due to be revised autumn 2014). A revised Governance strategy and increased risk management training across all staff levels will support developments the above in 2014/15. The Trust will progress the revised risk register format for the BAF and TRR and cascade principles to local risk registers. The committee will monitor the progress of modifications to the BAF and TRR. The Committee will develop ways to improve strategic prioritising of the Clinical audit plan for the Trust (informed by the Trust objectives and the BAF). Given changes in the CQC regulations, inspections and rating framework, the impact of MSFT service acquisition and priorities falling from the Francis report, it seems timely to consider a review of Trust strategic objectives. The opportunity could be taken to refine these into broad aims with more specific strategic objectives. 1.5 Challenges 2014/2015 The challenges for the next year will be to implement a reliable internal assurance framework (and early warning system) for the Trust which will embrace activities taken on along with Cannock, following the dissolution of Mid Staffordshire NHS Foundation Trust, while taking into account current uncertainties within the regulatory framework at national level. Formalisation of the new Fundamental standards of care and CQC inspection regime later in 2014/15 will mean some delay in receiving clear direction to finalise Trust requirements. As well as policies and strategies the Trust will need to align its objectives/ internal targets to meet requirements. Work must be maintained within the challenging expectations of greater efficiency savings, at the same time ensuring that patient experience and safety remains the driving priority. Page 7 of 8

8 Appendix 1 BOARD ASSURANCE COMMITTEE / QUALITY GOVERNANCE ASSURANCE COMMITTEE MEMBERS April May June July Aug Sept Oct Nov Dec Jan 2014 Feb 2014 March 2014 Dr J Anderson R Edwards A R J Harris A A B Jaspal Mander S Kalirai A A Professor A A A A * Kelly D Ritchie J Vanes * * A M Arthur R A C Etches D Loughton A A A A G Nuttall A R Dr J Odum A A A A A A R A = Apologies = Attended R = Representative attended Grey Shade = No meeting = Left the Trust * = membership changed QUORUM April to Aug 13: Four core members must be present, of which at least one must be a NED and one must be an Executive Director. QUORUM post Aug 13: Four members must be present consisting of 2 Executive Directors and 2 NED members. Page 8 of 8