Board Self-Assessment: Results Report

Transcription

1 Board Self-Assessment: Results Report Contents 1. Introduction Summary of Board Responses Other evidence Proposed Action Plan for 2016/ Conclusion... 8 Amber- Partially meets expectations Board Self-Assessment Results Report 1

2 1. Introduction The Board agreed at its last meeting that members would complete the self-assessment tool and review the results at its next meeting in March All Board members have completed this with the exception of the Medical Director who has recently taken up post. The Board is invited to discuss the content of the Report and in particular, review the proposed action plan for 2016/ Summary of Board Responses Overall the RAG ratings and comments received from Board members demonstrate a positive response to most aspects of Board function and performance. All Board members agreed that Board members are knowledgeable about quality issues and priorities, quality metrics and quality governance processes and structures. All Board members also believe that the Board actively leads on clinical quality and encourages a qualityfocused culture. The Board also agreed that it is clear on which responsibilities it has delegated and that there is a well-functioning clinical and internal audit process in relation to quality and corporate governance with clear evidence of action to resolve concerns. A number of Board members indicated a Red and Amber RAG rating (60% amber and 20% red) against Board members feel supported in their role through an effective training and development programme. Comments were no systematic training occurs. It would need to be tailored for each Board member and Good to have a framework for all new NEDs to complete we do an induction but perhaps could be more formalised. Some Board members (30%) indicated that in relation to the Trust Strategy having clear timeframes, assigned ownership and effective communication to staff and Board sub-committees the Trust partially meets expectations. It was felt that it would be useful to have more information on internal communication, that this expectation was hard to achieve as so many variables the question is where to best apply financial and managerial resources, timelines need to be reviewed and priorities do not have a clear timeframe and communications to subcommittees could be better. In terms of the Red RAG ratings, one Board member applied this to the statements relating to Board sub-committees conducting a periodic assessment of their effectiveness (20% rated this Amber) as well as there are clear, well understood structures and processes for the effective management of partnerships, joint ventures and shared services. A suggestion was made that RM needs to develop its own internal partnership model. 3. Other evidence The Trust has considered other evidence in relation to the domains and key areas of the Board self-assessment tool such as Trust systems and processes, policies as well as practice in other NHS Trusts; please see the table below. Amber- Partially meets expectations Board Self-Assessment Results Report 2

3 Domain 1: Strategy & Planning Structured, effective strategic planning processes are in place, and external and internal stakeholders are routinely involved. The Trust s overall Strategy has clear timeframes, assigned ownership for its implementation, and been effectively communicated to staff and Committees. Trust Strategy CoG and Trust Board routinely receive KPIs and Financial Plan; Trust Priorities workshop held for Board and CoG Members on strategic priorities; Board Away Day discussions focused on reviewing strategic priorities by Trust Division; Trust Five Year Strategic Plan discussed at Board, Sub-Committees and CoG; Internal and External Auditors routinely involved in discussions about Trust strategic planning matters. Weekly Trust Bulletins and monthly Bulletins from members of the Leadership Team to Trust Staff; Staff Open Meetings held with the Chief Executive, incl. Q&A sessions on average every two to three months; Governor Bulletins sent out quarterly covering key topics, forthcoming events and other important developments within the Trust and the wider NHS FT Sector. Executive Directors inform the Leadership Team on the Board position in relation to Trust Strategy at Executive Board Main risks are identified and there are clear responsibilities about ownership of risk. Risk Awareness Risk Management Policy is presented to Board; Board Assurance Framework reviewed quarterly by QAR and bi-annually by Board; KPIs reviewed at Board, CoG on a routine basis; Trust Risk Register reviewed at every QAR meeting. Amber- Partially meets expectations Board Self-Assessment Results Report 3

4 There is a process to monitor, understand and address current and future quality risks. The impact of initiatives is monitored on an on-going basis. QAR and AFC receive regular Serious Incident and Complaints Reports which include a lessons learnt section; Board Assurance Framework; Quality Accounts presented at each Board meeting as well as the draft and final Annual Quality Account; Results of adult inpatient surveys discussed at Board and QAR. Integrated Governance Reports at every QAR; Annual Clinical Audit results included in the Trust Forward Plan; annually reviewed by QAR Internal and External Audit Plan and opinion of Auditors. Domain 2: Capability & Culture Board Assurance and the Board s experience, capability and knowledge. Training and development programme. Knowledge on quality governance issues and priorities. Skills & Capability Nominations Committee review the balance of the Board on behalf of the CoG and the Trust Board, Appraisals of EDs carried out by CEO; Regular CQC updates at Trust Board, CoG and sub-committees; Productivity levels at The Royal Marsden discussed at Trust Board and CoG; Performance and Quality Reports discussed at Trust Board and CoG. NEDs invited to attend NED networking meetings as well as relevant events on an ad-hoc basis; Training events available for Trust Board and Governors hosted by external providers such as NHS Providers and Kings Fund; Subject specific seminars (e.g. IT) held for Trust Board although this is infrequent. NEDs visit hospital facilities and patient areas; Monthly and Annual Quality Account discussed at QAR, Trust Board and CoG; Trust staff attend QAR, Trust Board and CoG to deliver presentations on quality; Trust priorities workshops held for Board members. Amber- Partially meets expectations Board Self-Assessment Results Report 4

5 Domain 3: Processes & Structures The structure and workings of the Trust Board and the Council of Governors. Delegated responsibilities. Board Evaluation. Process of managing possible partnerships. Internal Audit Roles & Accountabilities Trust Board made aware of the work of its Sub-Committees through receipt of minutes and agendas; Public CoG and Trust Board minutes displayed on Trust website and shared with each of their members; Trust Constitution and SFIs includes Scheme of Delegation; Standing Orders define business conduct for CoG and Trust Board. Board Sub-Committees assist with gathering and verifying the evidence required for the Board Annual Self-Certification process; Terms of Reference of Sub-Committees reviewed on an annual basis; SFIs scheme of delegation. Board Evaluation discussed on Board Away Day; Trust Board Self-Assessment tool and action plan for 2016/17. Regular updates to Trust Board and Sub-Committees on the development and progress of Trust partnerships; Effectiveness and relationship with External and Internal Auditors discussed at Trust Board, CoG, AFC and QAR. Audit & Finance Committee receives reports from the Trust s Internal Auditors on a range of operational and regulatory issues. The Trust Board discusses Auditors recommendations and takes action to resolve any audit concerns. Amber- Partially meets expectations Board Self-Assessment Results Report 5

6 Patient Surveys. Staff Surveys. Engagement with other internal and external stakeholders. Stakeholder Engagement National Cancer Patient experience survey discussed at Trust Board; Survey of Adult inpatients discussed at Quality, Assurance & Risk Committee; CQC Inpatient survey discussed at the Quality, Assurance & Risk Committee; Engagement with patients on visits to wards. Annual Staff Survey discussed at Board; National Staff Survey discussed at the Quality, Assurance & Risk Committee; Engagement with front-line staff on visits to wards and at staff open meetings. Governor Framework of Engagement and Involvement; Board members and Governors attend a range of networking events; Representatives of key stakeholders on the Council of Governors, including Cancer Research UK, the Local Authority, and Clinical Commissioning Groups; Board members attend the Council of Governors and hear Governors, members, and patient views; NED ward rounds. Domain 4: Measurement Using information provided to hold management to account for the delivery of the Strategic Plan. Information Management Clinical, Operational, and Financial performance data (KPIs) is discussed at the Trust Board and CoG meetings as standing agenda items; Performance Review Group carries out quarterly reviews on operational performance and reports back to the Board; Financial Strategy Group introduced a system of Post-Project Evaluation every six months for projects which receive Trust funding. Amber- Partially meets expectations Board Self-Assessment Results Report 6

7 Independent Assurance on Board and Board Sub-Committee information. Independent External and Internal Auditor reports presented to the Audit & Finance Committee regularly; Staff and patient surveys provide independent commentary to the Board and the Governors on the Trust s performance. 4. Proposed Action Plan for 2016/17 Area of Board Self-Assessment Action Trust Strategy Trust Five Year Strategy and other key strategic documents to be reviewed and presented to Board at least once a year and to include clear timeframes, ownership & communication s plan to staff (Executive Directors). Skills and Capability Roles and Accountabilities Stakeholder Engagement Information Management Chairman to discuss and agree any learning and development needs for each NED following their appraisal process (Chairman and NEDs); Review the frequency and format of Trust Board Member visits to the Hospital / patient areas (Chief Nurse). Chairs of the Board Sub-Committees to review the interaction and exchange of information between the Sub-Committees as well as their periodic assessment plans (Ian Farmer and Nancy Hallett); Summary of how the Board and CoG interact to be provided to Board members for awareness purposes (Trust Secretary). Board to receive three year Patient and Public Involvement Strategy with help from Staff, Patient, and Public Governors for the Trust Board to review (Chief Operating Officer / Chief Nurse). Chairs of Sub-Committees to review information provided to and shared between Trust Sub- Committees to ensure it is succinct and can be used for performance management (Ian Farmer and Nancy Hallett); Auditors to review Trust KPIs (Marcus Thorman); Review of the level and frequency of auditor s reports to the main Trust Board to identify areas where this could be improved (Marcus Thorman). Amber- Partially meets expectations Board Self-Assessment Results Report 7

8 5. Conclusion Board members are asked to review the findings from the Board self-assessment and review / approve the proposed action plan for 2016/17. Amber- Partially meets expectations Board Self-Assessment Results Report 8