Board Memorandum on Quality Governance Arrangements – University Hospitals of Morecambe Bay NHS Trust
Executive summary and conclusion
Monitor has reviewed its assessment of applicant Foundation Trusts in relation in relation to Quality Governance. As a consequence it produced an amendment to the “Guide for Applicants” in July 2010. The revised guide introduced, in section 5.2.3.4, a new requirement that the Board of Directors of an NHS Trust applying for Foundation Trust to confirm, by way of a Board Statement and detailed Board Memorandum, they are satisfied that:
a. the trust has, and will keep in place, effective leadership arrangements for the purpose of monitoring and continually improving the quality of healthcare delivered to its patients; and
b. due consideration has been given to the quality implications of future plans (including service redesigns, service developments and cost improvement plans).
This Board Memorandum has been prepared to provide the Board with assurance that the four domains of Quality Governance
· Strategy;
· Capabilities and Culture;
· Processes and Structure; and
· Measurement
and the10 questions posed by Monitor’s Quality Governance Framework, as outlined in the Guide to Applicants July 2010, section 5.2.3.4, Appendix B13 and Appendix B14, are satisfied.
1. Strategy
Question / Key Area / Assurances & Future Actionsa. Does quality drive the trust’s strategy? / Trust Business Plan
Quality Improvement Strategy
Quality Accounts
Nursing and Midwifery Strategy
Nursing and Midwifery Quality Assessment Tools
Board Assurance
CQC Registration without conditions from 1 April 2010. / · Quality is embedded in the Trust’s overall vision and strategy - “the needs of our patients will drive everything we do”
· Updated annually (Approved 24 March 2010 Trust Board) and has six main strategic objectives. Quality underpins all of these i.e. to work in partnership with stakeholders to continuously improve patient safety and patient experience.
· Divisional Business Plans cascade key messages to each operational division and link to specific deliverables
· Progress against objectives in Business plans are monitored on a quarterly basis
· Strategic objectives regularly reinforced through Weekly News and Team Brief
· Quality Improvement Strategy approved by Trust Board on 26 May 2010
· Strategy aims to save lives by reducing hospital mortality rates, preventing harmful events, reducing variations in care and continuously improving patient satisfaction and outcomes
· Quality groups with Trust wide membership and individual executive leads will lead the Quality Improvement projects
· Overarching strategy that brings together national and local quality initiatives
· Strategy is monitored via the Clinical Quality and Safety Committee to Board.
· Quality Accounts produced for the first time in 2009/10. Level of patient and stakeholder involvement to be developed in 2010/11 though Patient and Public Involvement Strategy.
· Progress and outcomes against the Quality Improvement projects will be reported publically in the annual quality accounts
· Strategy developed and launched in 2009/10 to ensure that fundamental practices of care are consistent and high in all our hospitals. A One year on event was held in July 2010 with over 80 attendees
· Developed to allow wards to monitor the 15 fundamental care standards and act on findings
· Results reported via the Clinical Quality and Safety Committee to Board
· Ward to Board Assurance reports (GURU) are discussed at every Board meeting
· The Board regularly monitors Hospital Standardised Mortality Rates (included in Integrated Performance Report)
· Director or Infection and Prevention Control (DIPC) report taken quarterly to Trust Board
· Integrated Performance Report is produced to monitor national targets and quality indicators and self assess the trust against the Monitor Governance Rating criteria. Trends are shown graphically
· Key goal of achieving registration without conditions was met
· Annual review of scheme of governance for CQC planned for September 2010 at the same time as a review of the system of ensuring compliance
· Regular reporting of CQC requirements via CQSC and FPSC from Sept 2010
· Unannounced CQC Code of Hygiene inspection at RLI Jan 2010 – no breaches, 1 recommendation. CCQ satisfied with actions taken against the recommendation
· Unannounced CQC inspection, Maternity FGH, June 2010. Informal feedback positive, formal report received and to be reviewed via Clinical Quality and Safety Committee in September 2010
b. Is the Board sufficiently aware of potential risks to quality? / Risk Management Strategy
Risk Assurance Framework
Board to Ward to Board Assurance
Patient / Carer Feedback
Efficiency and Quality Improvement Programme (EQIP)
War on Waste
Clinical Engagement
Whistleblowing / · The Risk Management Strategy outlines the current status and systems in place to manage risk within the Trust. It outlines the key risk management objectives in relation to best practice and national standards
· The Board developed its Risk Assurance Framework in May 2009 to identify the principal risks faced by the organisation and ratified its Risk Management Strategy in July 2009
· The Risk Assurance Framework is reviewed throughout the year and monitoring reports highlighting the top risks are reviewed at the Trust Board or the Financial Performance Scrutiny Committee (FPSC) regularly. This review includes a detailed analysis of the mitigations necessary to counter each identified risk. A detailed review of the top risks facing the organisation is carried out at least annually. The Risk Assurance Framework for 2010/11 was approved by the FPSC in April 2010. The Board are due to review the Framework at the Board workshop in October 2010
· Each division / directorate also has a risk register. Divisional risk reports are being developed and are reviewed by the Integrated Risk Sub-Committee (reporting to the CQSC).
· The Trust rates each risk using a Qualitative Risk Assessment Matrix that assesses the likelihood and consequences of each identified risk
·
· “Board to Ward” Director of Infection Prevention and Control (DIPC) assurance reports are presented on a quarterly basis with the Health Care Associated Infections Key Performance Indicators Dashboard reviewed at the Infection and Prevention Sub-committee
· Patient Safety First Initiative – Ward to Board Assurance reports now a standing item on each Board meeting. The GURU Productive Ward dashboard is being rolled out to all wards along with the Nursing and Midwifery Quality Assessment tool (NQAT / MQAT) to allow real time feedback on wards
· The Trust participates in the National Inpatient and Outpatient Surveys with results monitored at Board level along with detailed action plans to improve performance. A Patient Experience Sub-committee, reporting to the CQSC is in place
· The Trust regularly monitors feedback on external sites such as NHS Choices and ensures all comments, both criticisms and complaints, are fed back to the relevant divisions. Negative comments are followed up and responses posted on NHS Choices with guidance on how to contact the Trust for further assistance through the Customer Care Department
· The Trust has used feedback from a variety of sources to identify issues that “matter to patients” and has used these to inform its Quality Improvement Strategy
· The Efficiency and Quality Improvement Programme (EQIP) is the Trust’s response to the financial challenge that faces all NHS organisations and the efficiency programme required as a consequence. The EQIP paper approved by the Board in January 2010 had three main aims:
1. Ensuring that we continuously improve clinical outcomes for patients
2. Being recognised as a top performing healthcare provider; and
3. Providing excellent value for money
There are three main principles around EQIP:
1. How clear and measurable gains in the quality of services and/or outcomes will be improved, or at the very least how services and quality will be maintained
2. How net cash-releasing efficiencies will be achieved, once additional costs have been taken into account, or how a measurable increase in service productivity will be achieved (with consideration of how this will be converted into net cash releasing efficiency)
3. How efficiencies will be realised over a set timescale
· Each scheme within the EQIP programme is allocated to one of 6 workstreams
W1 / Inpatient Clinical Pathways
W2 / Cross Bay Working
W3 / Support Services
W4 / Paybill Reduction
W5 / New Technologies
W6 / War on Waste & other schemes
· Each scheme has a lead manager and a lead clinician with an executive director taking overall responsibility for a workstream
· The Trust has used external benchmarking to inform some of the EQIP schemes for example Better Care Better Value Indicators which highlight areas where the Trust may be able to improve care and efficiency and the CHKS benchmarking
· A detailed Quality Impact Assessment (QIA) is undertaken in respect of each scheme within the EQIP programme incorporating the potential impact on patient safety, clinical effectiveness, patient experience and staff engagement to produce a RAG rating for each scheme.
· The CQSC have reviewed the QIAs associated with the 2010/11 cost reduction programme. NED challenge highlighted a need to change the scoring methodology
· The Trust monitors the on-going impact on quality of schemes through benchmarking with other trusts, external reviews, integrated performance report, Clinical Quality and Safety Committee, delivery of Key Performance Indicators.
· As part of the EQIP programme staff are encouraged to participate by sending their ideas of how the Trust can become more efficient
· The Trust encourages a culture of clinical engagement and involves key clinicians in all decisions. For example the introduction of the Lorenzo system was supported and road tested by clinicians from a number of disciplines before implementation. Working groups have been formed with hospital and primary care clinicians to improve processes around follow-up appointments and evidence based referrals
· The Trust has a Whistleblowing Policy that allows members of staff to raise concerns they may have. Staff are encouraged to raise any issues with their manager in the first instance but if they prefer not to they can raise concerns via the Human Resources department, to any Executive or Associate Director or to the Chair or any Non-Executive Director. Staff can raise issues confidentially if they wish to
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2. Capabilities and culture
Question / Key Area / Assurances & Future Actionsa. Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda? / Board Experience
Committee Structure
Board Development / · The Board of Directors consists of a team of seven executive / associate directors (including the Chief Executive), seven non-executive directors (plus the Chair) with a wide range of experience
· The Chair has a clinical background and has significant experience within the NHS at a senior level. The Non-Executive Directors have a range of experience from a number of different sectors and include a qualified accountant as the Chair of the Audit Committee and the Chair of the CQSC has a clinical background
· The Chief Executive has a clinical background and previously led a successful Foundation Trust and all other directors have previous NHS Board level experience and records of delivery against challenging operational and financial environments
· In line with best practice the Trust has developed a comprehensive committee structure that ensures Integrated Governance is achieved by the inter-relationship between committees rather than a single committee. The Audit Committee is the key committee for monitoring the Trust’s internal control processes, including issues from other Board committees
· The Trust has a clear committee structure for governance. The Clinical Quality and Safety Committee (CQSC) includes all Non-Executive Directors (NEDs), meets bi-monthly, reports directly to the Board and is supported by a sub-committee structure incorporating integrated risk, medicines management, patient experience and clinical audit
· The Clinical Quality and Safety Committee is chaired by a non-executive director with a clinical background and its membership was expanded in June 2010, to include all NEDs to ensure robust external challenge is received
· The Trust Board Committee structure and membership is shown in Appendix 1
· The Trust has recently strengthened this structure by increasing the number of CQSC meetings from four to five and the requirement for all NEDS to be members
· These main committees are further supported by a sub-committee structure. The network of supporting committees in relation to the Clinical Quality and Safety Committee is shown in Appendix 2
· The Board is supported by a divisional structure that was introduced in 2006 and amended in October 2009 to create the new Children’s and Family Division
· To ensure that the Board has the appropriate skills to carry out its role a detailed board development programme is ongoing. This plan has been developed following the Audit Commission paper “Taking it on Trust” and the feedback received from both Monitor and PWC in 2009. The executive and non-executive team have been appointed with specific skill sets but it is important that each Board member has a broad understanding across the whole range of issues that impact on an NHS Trust. All NEDs and executive / associate directors attend the development programme. Appendix 3 outlines in detail the programme over the past 2 years. Specific workshops have taken place on the Assurance Framework and risks, Board attitude to Governance and Risk, Quality Improvement Strategy, Quality accounts and findings of the Francis Enquiry into Mid-Staffs
· In addition, NEDs have organised two internal workshops (EQIP and CHKS data scrutiny), GURU presentation (Board May 2010, plus external courses (including North West Audit Chairs)
· Succession Plan for the Board – For the Chief Executive role this was discussed with the North West Leadership Centre by the current Chair and Chief Executive. For NEDs a clear skill set pla and recruitment process is in place
b. Does the Board promote a quality-focused culture throughout the trust? / Quality is embedded throughout the Trust
Patient focussed
Staff focussed / · The Trust has a number of key quality strategies that have been approved at board level which have been formulated with significant engagement from staff throughout the organisation:
o Quality improvement Strategy
o Nursing and Midwifery Strategy
o Productive ward
o NQAT / MQAT
· DIPC reports are reported on a quarterly basis to the Board
· Trust progress on MRSA infections is high profile with a “days since last infection” banner on the Trust’s intranet home page
· People Strategy – training & development, staff achievement awards for those undertaking training. Management development programme in place to inform managers of their corporate responsibilities, convey key messages
· CQUIN – key quality goals are aligned to nursing standards and form part of the quality improvement strategy
· Delivering Same Sex Accommodation – lead matron in post, dedicated training sessions and corporate communications to raise profile of issue. to lead in training etc
· Divisional Risk registers – discussed a regular divisional meetings and feed into corporate governance structure
· Patient safety walkarounds (Directors plus NEDs) in place
· Draft Patient and Public Involvement Strategy reviewed at Patient experience sub-committee (July 2010) and informal consultation with stakeholders underway
· Trust monitors patient comments on the NHS Choices website. These are fed back to divisions (whether positive or negative) and issues are followed up as necessary
· Findings of the annual Patient Survey are communicated to staff with detailed analysis by operational managers at the Hospital Management Team meeting. Improvement against 09/10 performance is included as a CQUIN metric in 2010/11
· Staff Survey – feedback is used to identify areas for development and has shown significant improvement in the last three years
· Culture of openness – reporting seen as a positive. Incidents are reported as part of the Integrated Performance Report. NPSA results show the Trust reports incidents swiftly and this is also reported in Quality Accounts
· Customer Care Department – has responsibility for complaints and PALS. Quarterly report is taken to the CQSC and a monthly summary is provided to the Board in the Integrated Performance Report
· Quality Impact Assessment on changes, staff are encouraged to share their ideas through the War on Waste project and all schemes within the EQIP programme are subject to a detailed quality impact assessment
· Weekly news, corporate communications used to communicate key messages around EQIP, War on Waste, DSSA, Infection Control etc. Individual Strategic objectives are reinforced in each issue
· Incident Reporting – The Trust has an agreed process for reporting, managing, analysing and learning from adverse incidents, complaints and claims is in place, in accordance with NHS guidance. Including:
· Incident Reporting Policy
· Serious Untoward Incident Policy
· Incident Investigation Policy
· Analysis of Incidents, Complaints and Claims Policy
· Learning Lessons Policy
· Complaint Management Policy
· Claims Policy
· Lessons Learnt reports are taken to each Integrated Risk Sub-committee detailing progress to date actions that have been taken
· Learning from complaints and claims is shared at the Patient Experience Sub committee
3. Processes and structures