Board Assurance and Escalation Framework

Transcription

1 Board Assurance and Escalation Framework Version - November

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3 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 (Self- Regulation) Risk and Risk Escalation Trust Assurance Framework Risk Registers Local and Service Risk Registers Directorate Risk Registers Corporate Risk Register Serious Incidents (SIs) 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 Performance and Accountability Framework Conclusion Appendix A Trust Assurance Framework

4 Appendix B Board Committees, Sub-committees and their s Appendix C Responsibilities of Board Committees Appendix D - Responsibilities of Executive Management s Appendix E Reportable Issues Log Template

5 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 combined provide the Trust with a robust assurance and escalation framework The Board Assurance and Escalation Framework (BAEF) demonstrates how the Trust s quality and risk systems, and learning from quality data is monitored by an effective committee structure and links to the NHS Improvement (NHSI) Accountability Framework 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; Assurance Source 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 Governance Route Patient and Carer Experience Workforce and Well-being Strategy, planning and Business Development Finance and Performance Committee Quality Assurance Committee Quality Assurance Committee Quality Assurance Committee Audit and Assurance Committee CIP Outcomes Finance and Performance Committee Patient Safety Health & Safety Committee Executive Team Quality Assurance Committee Executive Team Page 5 of 33

6 A description of the roles and accountabilities of committee structures in place in support of Board assurance The Reportable Issues Log presented to Trust Board once a month this concise report highlights key issues and risks arising within the preceding month, identifies a lead director and details progress with mitigating actions. 3. Background to Quality Improvement 3.1. 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 In July 2010, Equity and Excellence: Liberating the NHS 1 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 The Lord Carter Review 2 highlighted the importance of ensuring that workforce and financial plans are consistent in order to optimise delivery of clinical quality and use of resources Nursing and midwifery leaders have recently created a national framework for nursing, midwifery and care staff - Leading Change and adding value 3. This framework links with the NHS Five Year Forward View and has a central focus on 1 Kings Fund (2010) 2 Lord Carter report (February 2016) Operational productivity and performance in English acute hospitals: Unwarranted variations, An independent report for the Department of Health by Lord Carter of Coles 3 NHS England ( May 2016) Leading Change and adding value- A framework for Nursing & Midwifery Care Staff Page 6 of 33

7 reducing unwarranted variation and addressing a Triple aim of better health outcomes, patient experience and use of resources. 4. Quality Improvement Framework 4.1. We are committed to improving the quality of our care and the services we provide. Our patients value clinical outcomes together with their overall experience of our services. We strive to provide the very best experience for every person using our services. delivery of clinical quality and use of resources In line with the national context and expectations, LPT s responsibilities for quality can be summarised as follows To ensure quality is an explicit and integral element of corporate planning and performance management processes, with quality priorities detailed in our quality account and communicated throughout the organisation To deliver against all quality and safety standards identified by national regulators, local commissioners of services and people who use our services, their families and carers To implement national guidance from bodies such as National Institute for Health and Care Excellence (NICE) and NHS England Alerts, monitors compliance, identifies gaps and takes corrective actions To create a culture of continuous improvement and learning To have in place robust governance mechanisms to identify issues of concern, ensure lessons are learnt and actions are taken to continuously improve quality 4.3. Our Quality Strategy sets out our commitment to continuously improve our services by listening and taking account of service users experience and what they tell us. It is imperative that our organisation, teams and staff are clear about what quality looks like to us; and by the same token it is vital we translate our internal quality objectives into clear expectations for the people who use our services, so that they can understand what to expect from us We recognise that the delivery of high quality services can only be achieved by all our staff keeping quality as their top focus. It is important that our staff feel supported and empowered in their work because we expect them to deliver care in line with their respective professional codes of conduct, to lead the highest possible standards - standards that would be expected by family and friends, patients and the public. We will deliver our Quality Strategy by focussing on four strategic aims as follows: Ensure that we meet or exceed all national and local standards and targets Embed an effective self-regulation system that establishes a culture of accountability for quality Page 7 of 33

8 Demonstrate year-on-year improvements in patient satisfaction and patient involvement Deliver our Quality priorities through an annual quality improvement plan that is communicated to all staff and stakeholders 4.5. We believe that to improve the quality of care in a sustainable and affordable way we have to improve on developing the right climate for learning lessons from incidents, complaints and patient feedback continuing to use data for improvement and developing the knowledge base of our staff to accelerate the pace of change. We also acknowledge that clinical practice is constantly improving, offering new opportunities to improve the quality of care and we intend to harness the talents of all our staff to deliver continual improvement Improving quality is about making healthcare safer, more effective, patient centred, timely, efficient and equitable. Our central purpose is to provide the highest quality healthcare and promote recovery and hope to our patients. To do this we need to actively seek out the views of patients, carers, staff and work hard to build a culture of openness, honesty and support In framing our quality priorities we have derived our focus utilising the five key questions that the CQC ask and linking these to the three key aspects defined by Lord Darzi (effectiveness, patient experience and safety). Are Services Safe? Are Services Effective? Are Services Caring? Are Services Responsive? Are Services Well-led? CQC key questions 4.8. To review our Quality Strategy and agree our quality priorities we utilised the Listening into Action approach (LiA) with our staff. Our quality priorities map against the CQC findings and expectations and take account of staff requests to have focused and meaningful priorities that are simple to understand and relate to. In line with the CQC approach we acknowledge that achieving safe, effective and person centred care can only be sustained when a caring culture, professional commitment and strong leadership are combined to provide responsive accessible services for our patients The agreed LPT quality priorities for the next three years are; Ensuring our service users are safe (Safe care) Ensuring are care is effective (Effective care) Ensuring Person Centred care Our three quality priorities are underpinned by our approach to self-regulation which is reliant on good leadership and accountability at every level of the organisation for Page 8 of 33

9 delivering high quality services. It is all of our responsibilities to be curious about our work and to create a culture of improvement that is patient focused Improving safety, effectiveness and patient and carer experience aligns with our Sign up to Safety pledges and workforce and leadership plans. We are passionate about creating a culture that supports learning where people are comfortable asking questions, asking for and receiving feedback and are encouraged to innovate A key part of leadership and a safety culture is listening to our patients and carers as well as staff so that we are informed and learn from them. We are building a culture in which patients and staff can be confident their views matter and will be heard; and where all staff have what they need to provide the best possible care for patients whether through direct patient care or in the supporting services On an annual basis we will scope our improvement areas and take into account themes from CQC improvement actions, learning from serious incidents, complaints and patient feedback. We consistently map our quality priorities against the CQC parameters and our quality schedule; and our agreed indicators are mapped against our three priorities of safe, effective and person-centred care. Our quality milestones and indicators are re-defined annually as part of the Quality Account development and take account of commissioner quality requirements and our Commissioning for Quality & Innovation (CQUIN) schemes agreements Our Quality Strategy will be implemented through a delivery plan that forms an integral part of our five year plan. The delivery of our quality priorities will be encompassed in an annual Quality Improvement Plan(QIP), which links with our annual business plan and progress will be monitored quarterly through our business plan reviews To ensure each member of our staff understands our quality intentions, we will communicate our annual quality priorities widely using our intranet, team brief communication cascade system, senior leadership groups, Directorate meetings, induction and, corporate publications such as our Annual Report and Quality Account. 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. There are reporting and accountability mechanisms in place from the Board through to service line governance (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 and responsibilities are described in Appendices A-D. Page 9 of 33

10 6. Key assurance systems and processes 6.1. Patients, Carers and Public Involvement The Trust Board has approved a patient and Public Involvement 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:- Patient feedback 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 Localised meetings with service users and carers Board walks Inclusion of service users and carers in Trust work including Recruitment Friends and Family Test Co-design work programmes Peer panel complaints reviews 6.2. Staff Involvement 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 quality and risk issues. These include:- Raising Concerns at Work (Whistleblowing) Policy Appointment of Freedom to Speak Up Guardian Human Resources policies and procedures Exit Questionnaires National staff surveys Staff FFT/Pulse Survey (3 per year) Safeguarding policies and procedures Risk Management Strategy Incident and Serious Incident policy Care Quality Commission compliance with registration outcomes (including self-assessments) Information Governance policies and processes WWG Workforce and Wellbeing Page 10 of 33

11 Ask the Boss Listening into Action (LiA) Board walks Health & Safety Policy Feedback from staff is presented in a 4-monthly report to Trust Board including details of actions taken to address issues raised 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 s Attendance at the Mental Health Clinical Board Incident and Serious Incident process Complaints process NHS England Specialised commissioning meetings. Regular Integrated Delivery Meetings with NHS Improvement 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 Quality Assurance Committee Finance and Performance 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 Directorate meetings. Each Directorate considers its performance against key performance targets and reviews the performance of individual teams within the Directorate against these indicators. Outlying teams are identified and actions implemented to address the performance issue. Page 11 of 33

12 6.5. Monitoring Compliance with Care Quality Commission Essential Standards (Self-Regulation) On 1 April 2015 the CQC introduced a new Operating model shown below. The healthcare regulators (CQC) undertake three key functions for all NHS providers; to register clinical services; to monitor, inspect and rate providers; to enforce quality and safety standards On the 1 April 2016 the Trust s Self-regulation model was enhanced to enable the Board to monitor the risks of non-compliance in line with the requirements of Regulation 17 Good Governance (CQC April 2015) Self-regulation has been defined in a number of ways:- Control by oneself or itself, as in an economy, business or organisation When a group governs itself As a goal-guidance process aimed at the attainment and maintenance of goals A plan to eliminate risk behaviours. It includes self-monitoring, self-evaluation, and self-reinforcement Page 12 of 33

13 Self-Regulation support is divided into the following key components:- Confirming expected standards Monitoring and keeping track of performance Accountability and ownership for assurance Accountability and ownership for improvement The Self-regulation model aims to Prompt a change from a survey preparation mindset to that of continual readiness On 01 April 2015 the Fundamental Standards replaced the previous Essential Standards:- The five domains which are used to monitor and inspect NHS providers is shown below The Five Domains (CQC 2015) Are your services safe? Are people protected from abuse and avoidable harm? Are your services effective? Does people s care, treatment and support achieve good outcomes, promote a good quality of life and based on the best evidence Are your services responsive? Services are organised so they meet people s needs Are your services caring? Are staff treating patients with compassion, kindness dignity and respect Are your services well-led? The leadership, management and governance of the organisation makes sure the delivery of high quality personcentred care, supports learning and innovation and promote an open and fair culture Self-regulation has four key steps and this is shown in the Figure below. A Toolkit for Team Leaders describes the process for staff and all of the tools 4 (Devkaran S, et al. BMJ Open 2014) The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis Page 13 of 33

14 required for participating in Self-regulation. The Four key steps are outlined as - Step One Our time to shine (all services complete). This enables the team to collectively discuss how the service has improved the patient experience and quality of care and unite them on their improvement journey for the next year. Step Two Checklists (all services complete). This step enables teams to identify their strengths and weaknesses, and stop to review the impact they have as they provide care for both staff and patients. Team Leaders will then rate the service against each of the five domains informed by the Scoring guidance in the Toolkit for Team Leaders. Step Three (all services complete) Once Team Leaders have completed Steps #1, 2 their outcomes will be reviewed by either peers from across similar services or by other members of the Directorate. There may be a number of outcomes as a result of this including; changes to the teams/services scores for each of the five domains; further review of a subject focused aspect i.e. staffing etc; a new risk may be entered onto the risk register or a previous risk updated; or there may be no change as a result of Step #3. All teams with areas for improvement will identify an action plan to address any identified issues and these will be monitored by the directorate governance arrangements. Step Four Quality visit (agreed by governance lead). After completing Steps #1,2,3 a Team Leader in agreement with their Peer reviewer/s may request a Quality visit for their service. This decision would be supported through the Directorates governance arrangements to ensure a clear rationale for the request. In addition, the overarching Committee with responsibility for governing quality and safety (the Quality Assurance Committee QAC) may decide that a Quality visit is necessary for a particular team or service where the impact on either staff or service users requires review or where the controls are not adequately preventing impact on services users or staff. This decision is made at the QAC meeting by its members The QAC receive a quarterly report and scorecard which indicates the outcomes from services who have participated in self-regulation. Page 14 of 33

15 6.6. 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 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 Directorate 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 Page 15 of 33

16 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 has been achieved. Risk Management Strategy line of tolerance Directorate Risk Registers Each Directorate produces a risk register. This register is developed in response to risks identified through incidents, serious 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 Directorate Risk Registers are reviewed in the Directorate Governance meetings 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 Clinical Effectiveness. Similarly risks and assurances arising from internal audit activity will be highlighted to the Quality Assurance Committee by the Audit and Assurance Committee. Page 16 of 33

17 6.7. Serious Incidents (SIs) The Trust has a system and process in place to manage all Incidents and Serious Incidents. All incidents are reported through the electronic Safeguard system which provides the incident with a harm rating Safeguard is a web based system and training is provided to staff to enable them to report all incidents reliably. Training includes basic usage of the system and any programme updates that impact on staff using the system, as well as understanding what constitutes a reportable incident Each incident reported on the system generates a set of notification s to the relevant local manager for the service where the incident occurred. Local managers are responsible for ensuring immediate remedial action and appropriate management escalation has taken place The Patient Safety team undertake a daily (Monday-Friday) triage of all incidents reported in the preceding 24hrs Incidents meeting potential SI criteria require a 72 hour report to be completed. Following completion of this report it is reviewed by the Risk and Patient Safety Lead and a decision is made as to whether a formal review should be undertaken All SI reviews are considered by the Corporate SI Oversight along with the associated action plan to implement any recommendations The Corporate SI oversight reports in turn to QAC, highlighting trends or issues of concern and learning from serious incidents The Quality Assurance Committee receive a monthly and quarterly report on SIs 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 E 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 Trust Board development workshops External workshop and conference attendance by Board Directors Quality assurance of Trust Board minutes Maintenance and robust follow up of action log Comprehensive non-executive director induction Non-executive director supervision Page 17 of 33

18 Executive director supervision 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, any supplementary targets required by NHS Improvement and to ensure financial sustainability The Trust s Service Transformation (STG) identifies themes and potential CIP schemes from the STG workstreams: Multi-Specialty Community Provider (MSCP) Place-based approach Digital offer Emergency Care Vanguard / all-age Liaison Psychiatry Agile Working All CIP schemes, whether generated by STG or by individual clinical or enabling services, are evaluated, challenged and monitored by the CIP Outcome Panel During the development of the 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 impact 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 arise in other parts of the Trust Individual CIPs plans are scrutinised by the CIP Outcome Panel 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 responded to CIP delivery is managed through Directorate Management and Governance arrangements, with Corporate oversight of overall CIP performance via FPC. Delivery of the financial targets for each CIP is risk-assessed 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 CIP scheme will be reviewed by Page 18 of 33

19 the CIP Outcome Panel, 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 the process of delivery - will be suspended. Replacement schemes will be required for any scheme that is not progressed 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 Under the 2014 Care Act organisations that supply, publish or otherwise make available certain types of information, that is determined to be false or misleading commit an offence (where that information is required to comply with a statutory or other legal obligation). The offence also applies to the controlling minds of the organisation, where it can be shown that they have consented or connived in an offence committed by a care provider 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 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 available to support 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:- Page 19 of 33

20 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 Leading Together Senior Management Team Targeted training and development Direct team and individual feedback Operational Management Team meetings Trust communications Patient safety group Health & Safety Committee Action plans and recommendations are monitored through assurance systems within Directorates 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 is responsible for the VIP/celebrity/media visitor policy, which ensures the safeguarding of vulnerable patients and service users during media/publicity-related visits 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 flagged 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 (QAC) is the Committee with overarching responsibility for ensuring significant risks arising from external visits are being dealt with appropriately. The QAC: Receives a monthly summary report of all logged external visits Reports through to Board on immediate issues raised through the monthly Board Highlight report Page 20 of 33

21 The Trust Secretary is the lead contact for all non-cqc related visits. Key responsibilities are to: Ensure a log is maintained of this type of visit Provide monthly reports of logged visits to the QAC Complete any contractual requirements from the Trust s commissioners in relation to this type of visit eg monthly report to contract meeting, and informing at the earliest opportunity of visits such as unannounced by regulators, commissioners, or external agencies 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 works with the wider operational and strategic managers across clinical Directorates and enabling services 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 reviewed on a monthly basis at the Business Development with action taken in line with the information shared and reported on a quarterly basis to FPC Internal and External Sources of Assessment and Assurance Internal Integrated Quality and Performance Report (IQPR) Directorate Performance Scorecards Performance & Accountability Reviews Key Performance Indicators Reportable Issues log Minutes Committee Reports Directorate Governance Reports External assessments, reviews and benchmarking Care Quality Commission visits/ inspections National Accreditation schemes National Audits (e.g., suicide) Reviews of external independent reports Quality Accounts CQC Intelligent Monitoring Report Health and Safety Inspections External Audit Reports Page 21 of 33

22 Internal Directorate 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 Incidents Investigations Clinical Audit Clinical Presentations Quality Visits Service level dashboards CQC Compliance Visits Board walks External assessments, reviews and benchmarking Annual Audit Letter National Staff Surveys NHSLA Reports National Patient Satisfaction Surveys National staff surveys National Patient surveys NHS Protect Audit Reports Fire Authority Visits NHS England EPRR Self-Assessment annual Review NHS Protect Annual Review of Self- Assessment of Standards LOLER Inspection Certification Authorised Engineers reports for Statutory Compliance Clinical Audit At the start of the financial year the Clinical Effectiveness (CEG) 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 Directorate 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. Page 22 of 33

23 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 Constructed 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 based on the strategic risks identified within the Board Assurance Framework, has input from Board Directors, and is reviewed for 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:- Serious Incidents Formal coroner communications requiring the Trust to take action Regulation 28 letters Page 23 of 33

24 All claims Red rated complaints All employment tribunals Care Quality Commission reports and judgements Formal Notifications from professional bodies Notifications from local commissioners Performance notifications from NHS Improvement 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 Directors and Non-Executive Directors immediately of the issue and the risks posed to the Trust Performance and Accountability Framework The purpose of a performance and accountability framework is to articulate in one place the key processes and metrics which will govern the nature of the relationship between the Chief Executive Officer (CEO) and operational areas. From autonomy to escalation, the provision of support and improvement aids sustainable plans going forward The Trusts Performance Management and Accountability Framework is comprised of three dimensions: 1. Directorate / Service-Level Performance Management 2. Corporate Performance Oversight 3. Accountable Officer Performance and Accountability (P&A) Review Each Directorate has in place a formalised, written and approved Performance Management Framework. Wherever possible the Trust encourages the development of existing fora and governance structures over establishing additional and disparate groups with a sole performance focus Directorate Performance Frameworks describe the patient focussed values and ethos that are required to underpin effective performance of the service as well as the structures and processes in place for; Page 24 of 33

25 Establishing appropriate reporting units and hierarchies (for example these may be wards/teams, service-lines, or neighbourhoods, and will vary across operational services) The form of formal performance review (frequencies, fora and process including the shape and scope of performance information to be utilised) Internal escalation within services where performance is inadequate Incentives in place for rewarding good performance Establishing and reviewing demand and capacity analysis Establishing and managing active waiting list management Competency Frameworks and Training needs for operational management (to be operationalised via the appraisal process) At the highest level performance information is received monthly by the Trust Board through receipt of the IQPR, summary risk register report and any associated exception reporting The Trust Board delegates detailed scrutiny and review of performance to the Finance and Performance Committee (FPC). FPC receives the IQPR each month ahead of Trust Board and will undertake a thorough examination of the retrospective performance information within the IQPR and associated performance reports (for example the waiting time report) The central part of this process is an accountability review for all operational and corporate areas, which occurs every six months, at which agreement is reached on the level of escalation and autonomy. This model works alongside the self-regulation quality framework, drawing on all available and appropriate elements of quality assurance The clear focus will always be quality, the experience of patients, their health outcomes and safety. However, it is important that alongside this focus on quality, sits a focus on financial discipline and value for money. The measurement and monitoring process continues to place each operational area in one of five oversight categories which dictates the nature of the likely interventions and support available Areas deemed to be in special measures will be subject to a set of specific interventions designed to rapidly improve the quality of care and/or financial balance. Operational areas deemed to be in special measures will be required to develop a clear improvement plan and review operational capacity and capability. Risk Name Characteristics of this Category Level 1 High Risk Significant risk in 2 special or 3 domains measures Intervention Support Accountability High level of oversight and support. Identification of additional internal or external Direct accountability to CEO and DoF Page 25 of 33

26 support Level 2 Level 3 Level 4 Medium- High Risk Medium Risk Low- Medium Risk Moderate risks in two areas, or significant risk in one area Moderate risks Minor or moderate concern in one area Level 5 Low Risk Minor issues in one area High level of oversight and support Targeted support Targeted support Performance reported by exception through ET, Board and Subcommittees Identification of additional internal support Potential identification of additional targeted support Potential identification of additional internal support No additional support required Direct accountability to CEO and DoF Targeted additional accountability in area of risk 6 monthly review, although my need additional support in one area 6 monthly accountability review Contained within the accountability framework is the implicit requirement for development and support to operational areas. It is anticipated that each operational area will review its own development needs and work with the chief executive to ensure that the offer to staff is relevant and meets the needs of the Directorate. This process is outlined below Page 26 of 33

27 Understanding Development Needs Meeting Development Needs Services reviews existing capacity and capability to deliver plans, during first quarter of year Services work to ensure a development plan is in place by the end of follwing financial quarter. Plans reviewed at accountability review. Support is provided through day-to-day interactions with colleagues, learning and development, EMLA etc Additional support may be required for example:- Improving leadership Quality improvement Coaching, mentoring Benchmarking External capacity/capability 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 27 of 33

28 Appendix A Trust Assurance Framework Page 28 of 33

29 Appendix B Board Committees, Sub-committees and their s Page 29 of 33

30 Appendix C Responsibilities of Board Committees Finance and Performance Committee Strategic Workforce Audit and Assurance Committee Charitable Funds Committee Remuneration Committee Mental Health Act Assurance Committee Quality Assurance Committee SI Oversight Safeguarding Committee Infection Prevention & Control Committee Patient and Carer Experience Mortality Surveillance Health and Safety Committee Medical Devices Emergency Preparedness, Resilience & Description Assurance of financial and operational performance of Trust with focus upon impact upon quality of clinical services delivery. Business planning and capital considerations. Assurance of the workforce planning and OD delivery. Independent assurance for financial and governance processes. Trust Charitable funds approval and monitoring of spend, strategy development for income generation, and investment decisions oversight. Executive Directors remuneration and redundancies approval. Provides assurance for the continued management and monitoring of the MHA compliance and inspections. Assurance of quality and safety of clinical services and lead risk committee. Oversight of SI delivery compliance, themes, and standards. Oversight of Trust safeguarding incidents and developments eg training. Oversight of Trust monitoring and improvements to infection co control delivery. Monitoring of patient and carer experience and ongoing positive engagement. Review data on patient mortality, ensuring that the systems and processes in place to manage Mortality and Morbidity are robust and have clear Governance processes. Provide oversight and assurance that the management arrangements in place for health and safety are suitable and sufficient. Promoting continual improvement in all subgroups that report therein. Monitoring and scrutiny of arrangements in place for medical devices usage and life-cycle; giving assurance of quality and safety. To develop, implement, monitor and give assurance that the EPRR strategy, core standards and business continuity management arrangements are effectively managed within the Trust. Page 30 of 33