Quality & Safety Committee. Revised Clinical Programme Groups (CPGs) Quality & Safety Monitoring Reporting v3

Transcription

1 Betsi Cadwaladr University Health Board Committee Paper Item QS12/82 Name of Committee: Subject: Summary or Issues of Significance Quality & Safety Committee Revised Clinical Programme Groups (CPGs) Quality & Safety Monitoring Reporting v3 Following review of the Quality & Safety Committee s Annual Report and Terms of Reference, in July 2012, it was identified that in order to ensure the Committee continues to fulfil its delegated powers and authority, particularly, in relation to Strategies and Plans and Performance it was necessary to revise the CPG Quality & Safety reporting requirements. As indicated within the Quality & Safety Committee functions, extracted from the Terms of Reference and set out overleaf, the Committee will design a programme of work to ensure that there is a clear, consistent strategic direction, strong leadership and transparent lines of accountability for: 1. Strategies and Plans 2. Performance 3. Workforce 4. Governance The CPG Q&S Report template has been revised, developed and aligned with the 4 key areas. The revised report template is presented for review and agreement. Strategic Theme / Priority / Values addressed by this paper Healthcare Standard addressed Equality Impact Assessment (EqIA) Making it safe / better All n/a Recommendations: That the Q&S Committee approves the revised CPG Q&S Monitoring Report template for the remainder Author(s) Dr Lyndon Miles Chair - Quality & Safety Committee Nichola Pryce-Howard, Assistant Director, Quality & Safety 1

2 Presented by Grace Lewis-Parry, Director of Governance & Communications Date of report Date of meeting BCUHB Committee Coversheet v5.02 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board 2

3 QUALITY AND SAFETY COMMITTEE FUNCTIONS (extracted from Terms of Reference) The Quality and Safety Committee s focus is on all aspects aimed at ensuring the quality and safety of healthcare, including activities traditionally referred to as clinical governance. The committee will provide: evidence based and timely advice to the Board assurance in relation to safeguarding and improving the quality and safety of patient / service user centred care DELEGATED POWERS AND AUTHORITY The Committee will design a programme of work to ensure that there is a clear, consistent strategic direction, strong leadership and transparent lines of accountability for: 1) Strategies and Plans oversee the initial development and implications of strategies and plans of the LHB (and partners) ensure that the organisation, at all levels (including Clinical Programme Groups and Corporate teams) has a citizen centred approach, putting patients/service users, patient/service user safety and safeguarding above all other considerations 2) Performance ensure that the organisation, at all levels (including CPGs and Corporate teams) has the right systems and processes in place to deliver, from a patient / service user perspective, efficient, clinically effective, timely and safe services, which are based on sound evidence, and delivered by caring and competent staff ensure that decisions are based upon valid, accurate, complete and timely data and information 3) Workforce ensure that the workforce is appropriately selected, trained and responsive to the needs of the service, ensuring that professional standards, registration/revalidation/indemnity requirements and safeguarding arrangements are maintained ensure that there is an ethos of continual quality improvement and regular methods of updating the workforce in the skills and competencies needed to demonstrate quality improvement throughout the organisation seeking assurance on team working, collaboration and partnership working to provide the best possible outcomes for its citizens 3

4 4) Governance seek assurances on governance arrangements (including risk management) scrutinise the organisation s performance against Healthcare Standards for Wales (clinical standards / patient experience) ensure that all reasonable steps are taken to prevent, detect and rectify irregularities or deficiencies in the quality and safety of care provided, and in particular that: o sources of internal assurance are reliable, eg. internal audit and clinical audit teams have the capacity and capability to deliver o recommendations made by internal and external reviewers are considered and acted upon on a timely basis; and o lessons are learned from patient/service user safety incidents, complaints and claims. The Committee will also advise the Board on the adoption of a set of key indicators of quality of care against which the LHB performance will be regularly assessed and reported on through Annual Reports. 4

5 Clinical Programme Groups Quality & Safety (Q&S) Monitoring Report Template Name of CPG: Names and role of individual responsible for this report: Date of report: 1) Strategies and Plans i. Please provide an outline of CPG strategies, plans and priorities ii. Please outline how, in the development of the above plans, your CPG has ensured a patient centred approach that has patient safety and safeguarding as a priority 2) Performance i. Please outline how the CPG ensures that it has the right systems and processes in place to deliver, from a patient / service user perspective, efficient, clinically effective, timely and safe services, which are based on sound evidence, and delivered by caring and competent staff. Please also: describe how the CPG measures clinical performance and patient outcomes, providing a report for each of the service areas / types being provided (this should be whole system ie community and hospital, where appropriate) identify any variations in performance across North Wales, particularly concerns regarding quality and safety identify any challenges or areas for development ii. iii. iv. Please describe how the CPG ensures that decisions are based upon valid, accurate, complete and timely data and information Please describe the 1000 lives plus work being done Which work-streams, and at what stage for each Is data being submitted against the 1000 lives plus measures Is there a spread-plan for each work-stream How is the implementation of these plans being monitored and recorded Please provide a statement of assurance on the implementation of NICE and relevant professional guidance Implementation, compliance and audit against NICE and other relevant guidelines Compliance with NPSA, MHRA and other relevant alert notices 5

6 v. How does the CPG develop and monitor its Quality Improvement and audit plan Please outline relevant strategic learning from audit Please describe the findings and main actions for the following audits: Consent Capacity Act Deprivation of Liberty vi. Patient Experience and User Involvement. Please outline the results of patient surveys, with progress made on actions agreed as a result. 3) Workforce i. Please describe how the CPG ensures that the workforce is appropriately selected, trained and responsive to the needs of the service, ensuring that professional standards, registration/revalidation/indemnity requirements and safeguarding arrangements are maintained ii. iii. iv. Please describe staff experience within the CPG, include staff numbers, sickness absence, bank, locum and overtime activity. Please describe how the CPG ensures that there is an ethos of continual quality improvement and regular methods of updating the workforce in the skills and competencies needed to demonstrate quality improvement throughout the organisation Please provide a statement of assurance on how the CPG promotes team working, collaboration and partnership working to provide the best possible outcomes for its citizens. 4) Governance i. Please provide an assurance statement on how the CPG ensures proper governance and risk management performance ii. iii. iv. Healthcare Standards for Wales. Please provide a summary report on the standards reviewed Learning lessons. How does the CPG ensure that lessons are learned, shared and monitored? Please provide three examples (from an audit, complaint or a claim) that demonstrate how and what lessons have been learned and shared. v. Putting Things Right Dealing with Concerns 1. Complaints ( previous 12 month period) 1. Number and level (grade) of complaints received 2. CPG performance in relation to response time targets i. Trend analysis ii. 2 day acknowledgement by initial grade 6

7 iii. 30 day final response by initial grade 3. In how many complaints has there been an entitlement to Redress? 4. Ombudsman investigations i. How is the implementation of any resulting actions monitored? 5. What have been the lessons learnt from complaints received? 6. How assured is the CPG that the lessons have been learnt and that action required has been undertaken? 2. General Incidents (previous 12 month period) 1. Number of general incidents reported 2. Trend analysis 3. What have been the lessons learnt from incidents? 4. How assured is the CPG that the lessons have been learnt and that action required has been undertaken? 3. Serious Untoward Incidents (SUIs) and never events (previous 12 month period) 1. Number and level (grade) of SUIs reported to Welsh Government 2. What have been the lessons learnt from these SUIs? 3. How assured is the CPG that the lessons have been learnt and that action required has been undertaken? 4. Claims 1. Number and type of claims that remain open currently 2. Number and type of claims received within previous 12 months 3. Are there any recurring themes or trends within the claims received 4. What lessons have been learnt and/or actions taken following the investigation of a claim? 5. What have been the lessons learnt from the claims received? 6. How assured is the CPG that the lessons have been learnt and that action required has been undertaken? vi. Policy and Written Control Procedure Management Please provide an assurance statement on how the CPG ensures that its processes for policy and written controlled procedure management are effective? Appendix 1 included as an aide memoire. Please provide the CPG weblink address: Please report any other issues deemed appropriate to highlight to the Q&S Committee including but not restricted to: - Risk management - Health & Safety - Healthcare associated infections/infection control - Activity measures 7

8 Appendix 1: 4vi. Policy and Written Control Procedure Management 1. Does the CPG have a comprehensive list of all policies and written control documents with clear details of the title, organisation i.e. BCUHB or legacy organisation, review date and owner? 2. Does the CPG have a clear plan/timetable to review each policy, ensure it has been Equality Impact Assessed, gained approval (as the process stipulated in GC01 a and b) and been included on the intranet? 3. Has the CPG ensured all policies that have not been formally reviewed and updated to be BCU HB documents reflect current practice, policy, legislation or guidance? 4. Does the CPG have mechanisms in place to ensure all policy and written control documents within the CPG will be BCUHB documents only (not legacy documents) within a reasonable timeline as part of a planned approach? 5. Does the CPG ensure that all legacy documents will be withdrawn from the Intranet and any other areas in the organisation, including old hard copies held in files on wards once reviewed and updated? 6. Does the CPG have a nominated officer co-ordinating and gate-keeping the policy / written control documents process as per GC01 a and b? 7. Are the CPG nominated officer s contact details and purpose of role advertised within the CPG? 8