North Metropolitan Area Health Service
Mental Health
TERMS OF REFERENCE
Title: < Insert Program Name >) PROGRAM SAFETY QUALITY & RISK MANAGEMENT COMMITTEEScope: / All Program Areas
Category: / Leadership & Management Code: 2.3.1.
Reference No: / Cross reference with Local SQRM Terms of Reference
Date Authorised: / November 2005 / Review Date: / November 2006
Terms of reference Author/s: / Governance and Performance Development Team, NMAHS MH.
Terms of Reference Owner: / Area Executive
Contact Officer: / Manager, Governance and Performance, NMAHS Mental Health
Tel: / (08) 9347 6911
Fax: / (08) 9384 0339
E-mail: / NMAHS, MH GAP
1. SCOPE & AUTHORITY
the purpose of the committee is to ensure that there is a planned, systematic approach for the review of qualitative and quantitative data collected, analysed and used to drive quality improvement within a Clinical Governance Framework.
To advance and maintain standards using uniform internal control systems such as the AIMS incident-reporting database, risk register, and the complaints management system to create a safe quality service that focuses on the best outcome for both patients and the mental health workforce.
The committee will respond to clinical audits, risk assessment and risk management issues; internal and external Key Performance Indicators, ACHS recommendations, reports, OCP Clinical Governance reviews, OS&H and any other relevant reports.
The scope of the committee is non-executive and is tasked with recommending actions to the < Program > and Governance and Performance Team (GAP) as a result of reviews emanating from the local SQRM committees.
2. composition of COMMITTEE:
2.1 DELEGATIONS
The Program Clinical Director will assume the role of Program SQRM Chairperson. The SQRM is accountable to the NMAHS MH Area Executive Director.
2.2 MEMBERSHIP
Chairperson - Program Clinical Director
Program Manager x 1
Head of Clinical Service x 1
Nurse Director x 1
Governance and Performance Coordinator X 1
Each Program area will select one (1) representative from each of the following core service areas’ Joondalup/Clarkson, Mirrabooka, Osborne, Subiaco, SCGH, Graylands, Swan, Morley, and ICMHS shall be represented
Consumer Representative x 1
Memberships should be reviewed every 2 years or earlier if circumstances dictate. Periodic rotation of members’ - appointments is encouraged.
Any member unable to attend a meeting should advise the Chairperson and nominate a proxy representative, refer to item 6.7
2.3 REPORTING
The Chairperson will be required to report to the Program Management Team.
3. OBJECTIVES
To monitor, evaluate and promote quality health services by;
q Use of the WA and Office of the Chief Psychiatrist (OCP) Clinical Governance Framework to maintain and improve clinical standards under the Mental Health Pillars of;
1. Consumer Value
2. Clinical Performance and Evaluation
3. Clinical Risk
4. Professional Development and Management
q As per the Program Audit Schedule, undertake the review of reports, and
q Ensure the Program Quality Audit schedule is maintained
q Compare, benchmark and evaluate the outcomes service level audits
q Identify service gaps relative to quality, safety, risk management, clinical practice and develop strategies to address deficits.
q Communicate and direct recommendations to local SQRM committees and when required to NMAHS Mental Health Executive Group (MHEG) via the Program Management Team
q Disseminate information pertaining to quality activities and events
q Review of all registered risks monthly, develop (as required), track and report on the progress of all related risk treatment plans
q Provide evidence to demonstrate changes to practices and/or services as a result of evaluation. (e.g. policy review, consumer feedback, complaints management, Sentinel Event reporting and investigation (RCA), ensure that related RCA recommendations and related action plans and are progressed.
4. Terms of rEference
The committee will act as an independent assurer of the NMAHS MH and is responsible for advising the Program Management Team and Governance and Performance of best practice.
4.1 CLINICAL GOVERNANCE
q Monitor <Program > Clinical Governance structures, systems and processes as per WA Clinical Governance Guidelines 1.2
q Adherence to the following Australian Standards
o 8000-2003 Good Governance Principles
o 8001 Fraud and Corruption Control
o 8002 Organisational Codes of Conduct
o 8004 Whistleblower Protection Programs
q Compliance with Premiers Circular 2005/02 Corruption Prevention
q Review effective operation of internal and external audit program
4.2 RISK MANAGEMENT
q Oversee the <Program > clinical risk management system
Adherence to:
o Treasurers Instruction 825
o Australian Standard 4360: 1999/2004
q Implementation of Department of Health Policy, February 2005
q Implementation of the NMAHS, MH Risk Policy L&M 001
4.3 QUALITY IMPROVEMENT
· Oversee < Program > Quality initiatives
· Adherence to:
· Australian Council of Healthcare Standards quality framework and cycle
· Other accrediting bodies and the Royal College’s standards
· Quality Management System Requirements International Standard ISO9001:2000
To this end the committee will receive and review reports and work in conjunction with the all sub committees.
5 STANDING AGENDA ITEMS
q Area MH Strategic Directions
q Quality Action Plan
q Program Audit Schedule
q Risk Management
q Incident reporting / RCA / Sentinel Events
q Local SQRM audit reports
q Program KPI’s and Performance Indicators
q EQUiP recommendations & associated action plans
q Complaints Management
6. OPERATING PROCEDURES
6.1 QUORUM
For the membership to vote or make recommendations on issues there must be in attendance 50% plus one (1) members. In the event that there is not the required quorum present the recommendation must be ratified at the next scheduled AMHS Safety, Quality & Risk Management Committee meeting.
6.2 RECORDS (minutes/action statement)
The Chairperson ensure that a statement is recorded and circulated to all members within ten (10 ) working days of the meeting.
6.3 FREQUENCIES, TIME AND VENUE
Meetings will be held fortnightly, Venue XXXXXXX Time XXXXXXX
6.4 PECUNIARY INTERESTS THAT MAY CREATE A CONFLICT OF INTEREST
Where a member has a pecuniary interest in a matter, which is before the meeting for discussion, that member should not take part in the discussion or vote on the issue unless the Chairperson of the meeting is satisfied that the interest is so inconsequential as to be unlikely to affect the member’s judgement in the matter. This interest must be declared to the Chairperson and recorded in the minutes.
6.5 RIGHT TO COOPT
The right to coopt to seek advice and/or interview persons with special knowledge of issues under discussion
6.6 CONFIDENTIALITY
The members of the Area Mental Health Safety & Quality Committee are obliged to maintain the confidentiality of details of any discussion relating to the proceedings of the meeting where stipulated by the Chairperson. Otherwise once action statements/minutes are approved they will be made available for distribution.
6.7 PROXY
To ensure the ongoing management of core business all members will be required to nominate a proxy representative. If a sitting member of the committee is unable to attend the Chairperson and Proxy representative will be advised. The minute taker will ensure that on an ongoing basis all nominated proxy representatives are provided with the minutes and papers of the meeting.
6.8 EVALUATION
Each committee will be required to complete an annual evaluation, known as the Annual Committee Summary Report. This self-assessment is intended to evaluate the effectiveness, function, membership, purpose and outcomes of the committee including membership satisfaction with the activities of the committee
Changes to these Terms of Reference must be approved by the NMAHS, MHEG.
NB. To ensure consistency of Clinical Governance the Mental Health Area Executive is the
owner of all SQRM Terms of Reference this is designed to ensure that future changes are consistent across all program areas
Terms of Reference were endorsed 2005
REVISION HISTORY:
Approved/ Rescinded / Date / Committee / ResolutionNumber / Changes
November 2005 / 23/11/05 / MHEG / 66/05
February 2007 / 07/02/07 / MHEG / Changes to standing agenda items
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