THE IPSWICH HOSPITAL NHS TRUST Divisional Board TERMS OF REFERENCE Version 1.0 Purpose: For use by: This document is compliant with /supports compliance with: This document supersedes: Approved by: To provide Terms of Reference for the effective working of the Divisional Board, for use by Divisional Staff and for all staff for governance purposes within the Trust. All staff This document supports compliance with: 1. Trust Scheme of Delegation 2. Annual Plan New document Approval by Trust Board Approval date: 28 March 2013 Ratified by Trust Board Date Ratified 28 March 2013 Implementation date: 1 April 2013 Review date 1 April 2014 In case of queries contact: Responsible Officer Directorate and Department Linda Storey, Trust Secretary, Extension 6486 Executive Support, Trust Secretariat Archive Date i.e. date document no longer in force Date document to be destroyed: i.e. 10 years after archive date To be inserted by Information Governance Department when this document is superseded. This will be the same date as the implementation date of the new document. To be inserted by Information Governance Department when this document is superseded. Registered Document 1243 Page 1 of 6
Version and document control: Version number Date of issue Change Description* Author 1.0 01/04/2013 New Document Linda Storey, Trust Secretary This is a Controlled Document Printed copies of this document may not be up to date. Please check the hospital intranet for the latest version and destroy all previous versions. Hospital documents may be disclosed as required by the Freedom of Information Act 2000. Sharing this document with third parties As part of the hospital s networking arrangements and sharing best practice, the hospital supports the practice of sharing documents with other organisations. However, where the hospital holds copyright to a document, the document or part thereof so shared must not be used by any third party for its own commercial gain unless this hospital has given its express permission and is entitled to charge a fee. Release of any strategy, policy, procedure, guideline or other such material must be agreed with the Lead Director or Deputy/Deputy Director (for hospital-wide issues) or Divisional/ Departmental Management Team (for Divisional or Departmental specific issues). Any requests to share this document must be directed in the first instance to the Trust Secretary. Registered Document 1243 Page 2 of 6
THE IPSWICH HOSPITAL NHS TRUST DIVISIONAL BOARD TERMS OF REFERENCE Version 1.0 1. Purpose and Level of Accountability 1.1 Purpose 1.1.1 The Divisional Board has been established to create a single line of accountability for all aspects of performance including patient safety, patient experience, operational standards, financial performance and staff engagement relating to the XXX division. 1.2 Accountability The Divisional Board is accountable to the Trust Board and has responsibility to escalate any issues to the Combined Board which will have potential impact across the organisation. 1.3 Structure Trust Board Combined Board Divisional Boards x 3 Critical Care Delivery Group Trauma Group 1.4 Four Weekly Programme of Business The Divisional Board will have a four weekly rolling programme for conducting its business: Week 1: Clinical Governance and Risk Management Committee. Week 2: Operations and Performance. Week 3: Development session (including patient feedback). Week 4: Combined Board see separate terms of reference. 2. Specific Duties and Responsibilities Week 1: Clinical Governance and Risk Management Committee 2.1 Monitor the division s compliance and ensure delivery of statutory duties, national and local standards and targets and other obligations, and agree actions and responsibilities to address shortcomings. 2.2 Ensure the division takes action in response to controls assurance and risk assessments. Specifically, to review on a bi-monthly basis the schedule of outstanding internal and external audit recommendations related to the division in advance of review by the Combined Board and Audit Committee. Registered Document 1243 Page 3 of 6
2.3 Receive the minutes from the Risk Management Committee on a bi-monthly basis. 2.4 Use datix dashboard to regularly review the division s risks. 2.5 Ensure that the risk register is appropriately managed through the Rules of Engagement document. 2.6 Review divisional input to actions to manage/mitigate risks on the Board Assurance Framework. 2.7 Review clinical incidents and litigation report on a quarterly basis. 2.8 Agree clinical services strategy for the division as part of the overarching clinical services strategy reviewed by the Combined Board and approved by the Trust Board. 2.9 Approve and ratify divisional policy and guidelines as set out in the Trust s Scheme of Delegation. Week 2: Operations and Performance 2.10 To approve the division s policies and plans, and allocation of management, financial and physical resources in line with the Trust s strategic direction and annual plan: 2.11 Monitor the division s compliance and ensure delivery of statutory duties, national and local standards and targets and other obligations, and agree actions and responsibilities to address shortcomings. 2.12 Take an overview of the division s performance against its activity and income plan to ensure successful delivery against the plan, agreeing remedial action where required. 2.13 Oversee the division s approach to improving productivity and efficiency in all areas. 2.14 Set a cost improvement plan target for the division and monitor its delivery and receive assurances on project quality assurance scores. 2.15 Propose new Transformation schemes for the division for approval by the Combined Board. 2.16 Formally monitor and performance manage progress of the division s Transformation schemes including status reports, financial performance and risks, agreeing appropriate remedial actions where required. 2.17 Prioritise both capital and revenue business cases for review by the Combined Board. 2.18 Monitor business case implementation and review post implementation delivery. 2.19 Make recommendation to the Combined Board for the introduction of any significant activity or service. 2.20 Approve the flexing of capacity within the division to manage patient flow upon advice from the Chief Operating Officer. Week 3: Development Session including Patient Feedback Sessions to be designed and established by the division, with input from the executive team, other colleagues and external organisations where appropriate. Week 4: Combined Board see separate terms of reference. Registered Document 1243 Page 4 of 6
3. Level of Authority 3.1 The Divisional Board has delegated authority from the Trust Board to deliver its key duties and responsibilities. 4. Membership and Quorum 4.1 Membership 4.1.1 Membership of the Divisional Board will comprise: Divisional Clinical Director (Chair) Head of Nursing and Clinical Services Head of Operations Representation from each of the Clinical Delivery Groups: either Matron or Clinical Lead. Governance Manager Human Resources Business Partner Finance Business Partner IT Business Partner 4.1.2 The Divisional Clinical Director will chair meetings and in his absence the Head of Nursing/Clinical Services will act as Chair. If the Divisional Clinical Director and the Head of Nursing/Clinical Services are absent the Divisional Clinical Chair will nominate one of the other members of the Divisional Board to chair the meeting. 4.1.3 The Divisional Board may invite corporate leads and other members of staff, other key stakeholders and advisors to attend meetings as appropriate. 4.2 Quorum 4.2.1 The number of members required for a quorum shall be five. 4.2.2 Members are requested to send a deputy with the appropriate skills and knowledge to represent them if they are unable to attend a meeting. 3. Frequency of Meetings 5.1 Meetings will normally be held monthly. 5.2 Meetings may be held more frequently, as convened by the Chair. 5.3 The Chair has the authority to exercise an emergency or urgent decision where a particular issue requires a response that cannot be deferred to the next meeting. When this occurs, one of three actions may be taken: 5.3.1 Convene an urgent meeting, ensuring that the Combined Board has a quorum. 5.3.2 Email Members requesting their opinion or decision by a given date. The result will be determined by a majority of the votes of members. 5.3.3 Take Chair s urgent action. When this option is taken, any decision made must be taken by the Chair in consultation and agreement with at least three other Members. The exercise of such a decision shall be reported to the Divisional Board at its next meeting for formal ratification and the Trust Secretary informed. Registered Document 1243 Page 5 of 6
6. Arrangements for meetings and circulation of minutes 6.1 The agenda for meetings will be prepared by the Chair of the Divisional Board. 6.2 The agenda and reports for the meetings will be circulated by email one week prior to the Divisional Board meeting. 6.3 Action notes will be taken at each meeting to keep a record of the business and issues to be carried forward. 6.4 The Secretary for the Divisional Board will be responsible for meeting arrangements, circulation of documents and note taking. 7. Reporting arrangements 7.1 Action notes will be distributed to Members once completed following the meeting. 7.2 A monthly highlight report of the key issues discussed and decisions made across the rolling programme of meetings will be submitted to the monthly Combined Board Meeting. 7.3 The Divisional Board will receive regular reports from any reporting sub-groups that it establishes. 8. Process for Monitoring the Effectiveness of the Above The effectiveness of the Divisional Board will be monitored through: 8.1 An annual review of the Terms of Reference. 8.2 The Governance Manager will keep under review the attendance at the Divisional Board meetings and take any necessary action to ensure that meetings are held in accordance with these terms of reference. 8.3 An annual review of the effectiveness of the meeting. 9. Ratification of These Terms of Reference and Review Arrangements 9.1 Reviewed at the Trust Board Meeting on 28 February 2013. 9.2 Approved by the Trust Board Meeting on 9.3 To be reviewed annually: next review March 2014. Registered Document 1243 Page 6 of 6