Trust Board Meeting: Wednesday 13 May 2015
TB2015.61
Title
Update on Quality Governance Framework
Status
For information, discussion and decision
History
This paper has been presented to Quality Committee in April
2015 (QC2015.38) and to Trust Management Executive in April
2015 (TME2015.112)
Board Lead(s)
Tony Berendt, Medical Director
Key purpose
Strategy
Assurance
TB2015.61 Update on Quality Governance Framework
Policy
Performance
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Executive Summary
1. The primary objective, both for the Trust and Monitor, of the Quality Governance
Framework is to ensure that patients receive safe, high quality care in keeping with the
Trust’s values and strategic objectives.
2. Improvements in the framework should be viewed in part through the lens of building a
just culture where the organisation and its staff continuously identify, assess and seek
to mitigate risks, and learn lessons when quality defects (at their most extreme,
causing patient harm) occur.
3. Since the Monitor assessment in September 2014, the immediate learnings from that
process, and the detailed feedback subsequently received by the Trust, work has been
in progress to improve several elements of the Quality Governance Framework (QGF).
4. At the time of the September assessment, the Trust, with endorsement from a limited
assurance review by the Trust internal auditors, KPMG, had self-assessed the QGF
score at 2.5. Monitor assessed the Trust at 4.5. The upper limit for authorisation is 3.5.
5. This paper sets out much work that has been done to strengthen the Quality
Governance Framework since September 2014. Of note, however, is that despite this
work, several Never Events have occurred in different settings in the Trust,
demonstrating the emergent nature of risk and the need to see the QGF as but one
element of a continuous process of quality monitoring and improvement.
6. The paper has previously been received and discussed at Quality Committee
(QC2015.38), where the principle of rescoring the Quality Governance Framework
scores was agreed, and at Trust Management Executive (TME) (TME2015.112) where
new scores were agreed based on the progress deemed to have been made.
7. Recommendation
The Trust Board is asked to note the progress made in Quality Governance and to
consider whether the evidence presented justifies the favourable movement in the
QGF scores from those previously determined by Monitor to those proposed by TME.
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Update on Quality Governance Framework
1.
Purpose
1.1. The purpose of this paper is to provide the Trust Board with an update on the
work completed, and in progress, to address issues in the Quality Governance
Framework, as identified by Monitor in its assessment undertaken in September
2014. In addition, the paper sets out the modified Quality Governance
Framework scores that the Trust Management Executive proposes are agreed in
response to this body of work.
2.
Background
2.1. The Quality Governance Framework (QGF) sets out a series of questions that
the Trust must answer, evidencing each response and self-assessing with a
score. The total score is the sum of scores for each of the ten questions posed; a
perfect score would be zero, and the worst possible score 40, (which would
represent major omissions in quality governance in each of the ten domains).
2.2. Monitor has set a threshold for authorisation of applicant Foundation Trusts of 3.5
or less.
2.3. Prior to the assessment, the Trust self-assessed with a score of 2.5. Following
assessment, Monitor scored the Trust at 4.5. Improvement, to Monitor’s
satisfaction, is essential for authorisation.
2.4. Monitor provided the Trust with detailed feedback and while a formal action plan
was not considered appropriate by either the Trust or Monitor, key actions to be
undertaken were agreed. The remainder of this paper considers progress with
those actions.
2.5. It is however essential to hold in mind that the primary objective, both for the
Trust and Monitor, of the Quality Governance Framework is to ensure that
patients receive safe, high quality care in keeping with the Trust’s values and
strategic objectives. Improvements in the framework should be viewed in part
through the lens of building a just culture where the organisation and its staff
continuously identify, assess and seek to mitigate risks, and learn lessons when
quality defects (at their most extreme, causing patient harm) occur.
2.6. Since the Monitor assessment process, the Trust has experienced an
unprecedented number (6 in 2014/15) of Never Events, which are Serious
Incidents Requiring Investigation that are widely considered to represent failures
of basic safety processes, and hence to be entirely avoidable. Progress against
the action plan for improving quality governance since September 2014 must be
viewed with these events in mind, which demonstrate the emergent nature of risk
and the QGF should be viewed as but one element of a continuous process of
quality monitoring and improvement.
3.
Areas for improvements in Quality Governance / Progress
3.1. This section provides a complete assessment of all elements of the QGF. It also
outlines the progress against the commitments made by the Trust in writing to
Monitor, following the formal feedback received from Monitor.
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3.2. Does quality drive the trust’s strategy? (1A).
3.2.1. A refreshed Quality Strategy has been agreed by the Trust Board (January
2015, [TB2015.09]) following discussion and approval at the Trust
Management Executive and the Quality Committee in their December
2014 meetings [TME2014.314 & QC2014.85].
3.2.2. Following the January 2015 Trust Board meeting, workshops involving
approximately 100 staff and patient representatives were held later that
month to contribute to the Quality Priorities and the Quality Strategy
Implementation Plan. The draft Implementation Plan was reviewed at
Quality Committee in February 2015 [QC2015.05].
3.2.3. The priorities as set out in the Quality Account [QC2015.23] flow from the
refreshed Quality Strategy and are referenced in the Implementation Plan.
3.3. Is the Board sufficiently aware of potential risks to quality? (1B).
3.3.1. In its December meeting, the Quality Committee received a paper
[QC2014.87] detailing an enhanced mechanism for use with CIP schemes
from January 2015. The enhanced mechanism is designed to test and
monitor the potential impact of CIPs interacting and aggregating to affect
risk levels.
3.3.2. This arrangement will increase the understanding and collective challenge
on schemes which cross Divisions or have a Trust-wide impact. Divisions
will be able to identify schemes from one Division which impact adversely
on another.
3.3.3. A report format demonstrating aggregation of identified risks has been
presented to the April 2015 Quality Committee [QC2015.28] and has
subsequently been reviewed at the April 2015 meeting of the CIP
Executive Group.
3.3.4. Divisional quality metrics for key Trust-wide measures have been
presented to the Quality Committee and Trust Board in the Quality Report
since January 2015 [TB2015.05, QC2015.04, TB2015.28 and
QC2015.24].
3.3.5. The Trust has recently revised, and further developed, its existing
guidance in relation to the identification and description of risks used in
risk registers [QC2014.87]. The revised guidance is being incorporated
into CIP scheme processes to enable risks to be more effectively
considered by staff developing CIP schemes.
3.3.6. The Trust is developing a specific risk register for CIP programmes where
there are interdependencies between schemes, or aggregated and
cumulative impacts.
3.3.7. The Trust has developed a standard recording tool and Standard
Operating Procedure (SOP) which will be used by Divisions’ Clinical
Governance and Risk Practitioners (CGRPs) on a quarterly basis to review
progress with risk registers within Divisions. This was implemented from
mid-January 2015 on a quarterly basis, with a briefing session and
educational workshop with CGRPs held in early January.
3.3.8. A series of workshops for Divisional Management Teams was provided
during January to March 2015 to refresh knowledge and understanding of
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risk registers, the reporting and management of risk and the process of
escalation.
3.3.9. A weekly “risk management surgery” takes place every Friday, providing
staff with an opportunity to discuss any aspect of risk with a member of the
Assurance Team.
3.3.10.
The Board continues regularly to receive and discuss reports on
Serious Incidents Requiring Investigation, including Never Events and
actions arising from them [QC2015.25]
3.4. Does the Board have the necessary leadership, skills and knowledge to
ensure delivery of the quality agenda? (2A)
3.4.1. The Board has remained stable since the Monitor assessment in
September 2014 and its leadership, skills and knowledge are
undiminished.
3.4.2. The Interim Medical Director was appointed to the substantive post in
October 2014. In March 2015, Dr Clare Dollery commenced in post as full
time Deputy Medical Director, with substantial experience in quality
improvement, bringing additional high-level leadership and expertise to
Board-level discussions. Dr Dollery is a full member of TME, and of the
Quality Committee, to further emphasise the importance of the quality
agenda.
3.5. Does the Board promote a quality-focused culture throughout the Trust?
(2B)
3.5.1. Monitor’s letter of 5 November 2014 on Quality Governance Framework
findings was immediately distributed to Board members and considered at
the Board’s Part II meeting in November. The results were discussed by
the Board as part of the Board Seminar in November 2014, and the
Quality Committee considered a range of papers addressing Monitor’s
findings at its meeting in December 2014.
3.5.2. The Trust is working to build substantive workforce capacity through its
actions on recruitment and retention.
A revised multi-professional
Education and Training Strategy has been commissioned through the
Education and Training Committee for completion in March and agreement
by the Board in May. This Strategy will address protected time for training
and appraisals.
3.5.3. All Consultants’ job plans within the Trust include one session (PA) per
week for activity with regard to revalidation, which includes quality
improvement activity (such as the supervision of clinical audit), continuing
professional development and time to prepare for appraisal.
3.5.4. The substantive Medical Director is now supported (from March) by a new
full time Deputy Medical Director and an Associate Medical Director for
Medical Workforce, increasing the capacity in the Medical Director’s
Office. Plans for the development of a Medical Engagement Strategy have
been slowed down as the new members of the team take on their full
portfolio case load. This will be progressed in late spring 2015.
3.5.5. The Board actively supported the Quality Strategy Implementation Plan
events held in January 2015. In March, a session at the Board Seminar
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was given over to an in-depth consideration of quality and organisational
culture. This was also attended at the Board’s request by Divisional
Directors or their representatives.
3.6. Are there clear roles and accountabilities in relation to quality governance?
(3A)
3.6.1. Following the review of the role and functioning of the Clinical Governance
Committee (CGC), completed and reported to Trust Management
Executive and the Quality Committee [QC2014.93 and TME2014.330],
there is now a revised sub-committee structure, an escalation process
clearly defined in the Terms of Reference of the CGC and each of its subcommittees, and a clear link between goals in the refreshed Quality
Strategy and the objectives of relevant CGC sub-committees.
3.6.2. Dr Clare Dollery commenced as full-time Deputy Medical Director on 1
March 2015, and has taken over Chairmanship of the Clinical Governance
Committee. Dr Dollery is a full member of TME and the Quality Committee
to further emphasise the importance of the quality agenda. She is
supporting the development of the new Clinical Effectiveness subcommittee of the CGC, which is chaired by the Associate Medical Director
for Medical Workforce and Engagement.
3.6.3. The Board lead for Quality remains the Medical Director, and the lead for
the Patient Experience domain of quality remains the Chief Nurse.
3.7. Are there clearly defined, well understood processes for escalating and
resolving issues and managing quality performance? (3B)
3.7.1. At its meeting on 27 November 2014, the Trust Management Executive
received and discussed a review of the policies and practices for
escalating issues to quality performance. The committee approved the
proposed changes to relevant policies to strengthen the processes for
escalation [TME 2014.298].
3.7.2. The paper reinforced the importance of early reporting of incidents by
clinicians, according to NHS England’s framework for escalation of
incidents according to their severity.
3.7.3. The Quality Committee discussed and endorsed the revised approach at
its December meeting [QC2014.86]
3.7.4. An enhanced training programme commenced from 1 February 2015, with
workshops held with Clinical Governance Risk Practitioners working in the
Divisions. A nursing Grand Round has been presented dealing with
serious incidents and escalation pathways.
3.7.5. A standardised reporting template for escalation issues has been
implemented.
3.7.6. There has been discussion at TME and at CGC regarding the new
escalation framework and the implications and consequences of this.
Improvements in performance times for the declaration of serious incidents
have been considerable and are described in QC2015.25 considered at
the April 2015 meeting of the Quality Committee.
3.7.7. Coincident with this work on escalation, a number of Never Events have
been declared since October 2014. All have been escalated to the Board
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and considered in Board and Quality Committee papers. Reporting times
have improved for the Never Events as well as for other SIRIs, as
described in Quality Committee report [QC2015.25].
3.7.8. The implications of the Never Events in the context of overall mortality and
harms, and of work to build a universally open and just culture, were also
considered at a Trust Board Seminar session on quality held in March
2015 with Divisional representation.
3.7.9. The Quality Bulletin newsletter process was reactivated in January 2015.
Work is ongoing to ensure an optimal style and content for sharing
learning across the organisation.
3.8. Does the Board actively engage patients, staff and other key stakeholders
on quality? (3C)
3.8.1. The Board continues to engage patients, staff and stakeholders on quality
as previously described in the full QGAF document.
3.8.2. In January 2015 Board members hosted and attended two large-scale
workshops on the Quality Strategy and Implementation Plan, which were
used to inform the plan and the 2015-16 quality priorities as set out in the
Quality Account [QC2015.23]
3.8.3. Following the election of the Board of Governors, a training and induction
programme is underway to ensure this key group is fully inducted including
into quality issues, and is engaged with the Board.
3.9. Is appropriate quality information being analysed and challenged? (4A)
3.9.1.
The Board Quality Report and the Integrated Performance Report present
quality information to the Trust Board monthly regarding:
•
The delivery of national targets;
•
Safe staffing levels
•
Nursing sensitive quality indicators
•
Other Trust-wide quality indicators
•
Key Division-specific indicators of high importance
•
Patient experience metrics
3.9.2.
The two most recent Board Quality Reports, considered at the April 2015
Quality Committee meeting [QC2015.24] and the May Trust Board
[TB2015.48], demonstrate the current state of data presented including
many metrics that are shown at Divisional as well as Board level.
3.9.3.
A full listing of other quality metrics is beyond the scope of this document
and remains as set out in the full QGF document.
3.9.4.
Further review and development of quality metrics is planned during 201516 linked to work to establish a Trust performance information unit (see
overleaf).
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3.10. Is the Board assured of the robustness of the quality information? (4B)
3.10.1. The Board is assured of the quality of its performance management data
by means of data quality structures and a data quality strategy supported
by appropriate policies and procedures. An Information Governance and
Data Quality Group (IGDQG) meets bi-monthly and reports to the Health
Informatics Committee, a sub-committee of the Trust Management
Executive; each Division has a corresponding group which reports to the
IGDQG.
3.10.2. Each IPR indicator is assigned a rating of 1-5 based on the level of
assurance obtained and a Red/Amber/Green rating to indicate the level of
confidence in the indicator based on the available level of assurance. All
indicator ratings and supporting evidence are held on the Trust’s
HealthAssure system. Each indicator owner is required to review the data
quality of their indicators on a quarterly basis. The rating given to each
indicator is reviewed annually by the IGDQG.
3.10.3. A full briefing on data quality issues was brought to the Trust Board in
January 2015 [TB2015.11]. Further updates will be included in six-monthly
information governance updates to the Board which have been
incorporated into the cycle of business agreed at the Trust Board in March
2015 [TB2015.38].
3.10.4. The Board’s Audit Committee receives external and internal audits relating
to data quality. External audit of the Trust’s Quality Account takes place
each year and includes substantive testing of sample quality
indicators. The latest audit of the Quality Account by the Trust’s external
auditors was considered by the Board’s Audit Committee at its September
meeting as paper AC2014.50. The Trust’s internal auditors review data
quality on an annual basis. This was last reported to the Board’s Audit
Committee in April 2014, giving the Trust an overall rating of ‘Significant
Assurance’. External audit of the 2014/15 Quality Account commences in
mid-May as set out in the draft Quality Account [QC2015.23].
3.10.5. Benchmarking is undertaken at each IGDQG meeting of the Trust’s data
quality using the national Secondary Users Service data quality
dashboard. The Trust’s performance is benchmarked both against national
performance levels and against local comparator Trusts.
3.10.6. A Clinical Audit Annual Report was considered by the Board’s Audit
Committee in November 2014 [AC2014.69]. This set out categories of
audit required of each Division as a result of the Trust’s Clinical Audit
Strategy, including all relevant National Clinical Audits as defined by the
Healthcare Quality Improvement Partnership (HQIP). The Annual Report
explained that in 2013/14, 65 mandatory and 176 non-mandatory audits
were undertaken by the Trust’s Divisions and that during the year, OUH
participated in 100% of the national clinical audits and 100% of the
national confidential enquiries in which it was eligible to participate.
3.10.7. The draft Quality Account for 2014/15, reviewed at the April meeting of the
Quality Committee [QC2015.23] identifies 48 national clinical audits and
three national confidential enquiries covered relevant services that Oxford
University Hospitals NHS Trust provides. During that period the Trust
participated in 100% of the national clinical audits and 100% of the
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national confidential enquiries in which it was eligible to participate. Also in
2014/15, the Trust undertook over 280 (10/3/15) registered local clinical
audits. Thus in total, the number of registered audits undertaken rose from
241 in 2013/14 to 331 in 2014/15.
3.10.8. At its November meeting, the Audit Committee asked the Medical
Director’s office to consider the balance of local and national audit input
and the effectiveness of the clinical audit programme. This work was
expected to be undertaken by the Deputy Medical Director who
commenced in post in March 2015, and whose proposed approach for the
review of the clinical audit strategy was presented to the Audit Committee
in April 2015 [AC2015.32].
3.10.9. Based on the Monitor feedback regarding the resources available to
undertake clinical audit, the Medical Director and Director of Clinical
Services undertook to review the adequacy of resources in relation to
clinical audit. The update was provided to TME in April 2015
[TME2015.103] as previously discussed in Audit Committee [AC2015.32].
3.11. Is quality information being used effectively? (4C)
3.11.1. OUH participates in a wide range of benchmarking activities, but
recognises that benchmarking information needs to be presented to the
Board using a wider group of peers than the Shelford Group of teaching
hospitals, and that national benchmarking is more visible to Board
members.
3.11.2. By the end of March 2015 the Trust aimed to develop a programme of
work to review all existing reports and the benchmarking data used within
them to provide assurance to the Board. The programme was to be
implemented from April 2015.
3.11.3. The Trust Executive and Board has agreed to develop a dedicated
performance information unit to coordinate, quality assure and deliver
performance information to the Board.
5. Discussion on scorings.
5.1. Appendix 1 (attached) shows changes in the QGF scores over time. Noteworthy
increases in scoring (worsening in rating) accompanied external assessments from
RSM Tenon in October 2012 and Monitor in November 2014.
5.2. The scoring matrix and this paper were discussed at TME in April, with the various
scores examined and challenged. TME was assured by evidence of improved
governance as set out in this paper and the supporting papers underlying it. On
that basis, TME recommended the following:
No. Proposal
1a
1b
2a
2b
Revised
score
A reduction in the score of 0.5 to 0.0 relating to quality driving
0.0
Trust strategy
Maintenance of the score for Board awareness of risk;
0.5
improvements in escalation of concerns and incidents being partly
offset by the multiple Never Events
Maintenance of the score for Board leadership
0.0
Maintenance of the score assessed by Monitor for promotion of a
0.5
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No. Proposal
3a
3b
3c
4a
4b
4c
Revised
score
quality culture, also due to the impact of the Never Events
A return to a score of 0.0 for roles and responsibilities
A reduction from 1.0 for the score on escalation processes
Maintenance of the score for engagement with patients, staff and
stakeholders
Maintenance of the score for Board challenge and analysis of
quality information
A reduction from 0.5 to 0.0 for Board assurance of the robustness
of quality information
A maintenance of the score for effective use of quality information
Total proposed score
0.0
0.5
0.5
0.0
0.0
0.5
2.5
6. Evidence Review
6.1. In addition to the evidence listed in the body of this paper the Assurance Team are
in the process of collating a refreshed evidence base to support the selfassessment results. A full list of the supporting evidence available to provide to
Monitor is attached at Appendix 2, for information.
7. Recommendation
7.1. The Trust Board is asked to:
•
•
note the progress made in Quality Governance; and
Consider whether the evidence presented justifies the favourable movement in
the QGF scores, from those previously determined by Monitor, to those
proposed by TME.
Dr Tony Berendt, Medical Director
May 2015
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Appendix 1
Appendix 1: OUH Quality Governance scores, 2012-2015
Oct 2012
RSM
Tenon
Score
Dec 2012
OUH Selfassessment
May 2014 OUH
selfassessment
and KPMG
April 2013
OUH Selfassessment
Monitor
November
2014
OUH selfassessment,
April 2015
0.5
0.5
0.5
0.5
0.0
0.0
0.0
0.0
0.0
0.0
0.5
0.5
0.0
0.5
2a. Does the Board have the necessary leadership, skills and
knowledge to ensure delivery of the quality agenda?
0.0
0.0
0.0
0.0
0.0
0.0
0.0
2b. Does the Board promote a quality-focused culture throughout the
trust?
Processes and Structures
3a. Are there clear roles and accountabilities in relation to quality
governance?
0.5
0.5
0.5
0.0
0.0
0.5
0.5
0.0
0.5
0.5
0.5
0.0
0.5
0.0
3b. Are there clearly defined, well understood processes for
escalating and resolving issues and managing quality
performance?
0.5
0.5
0.5
0.5
0.5
1.0
0.5
3c. Does the Board actively engage patients, staff and other key
stakeholders on quality?
0.0
0.5
0.5
0.5
0.0
0.5
0.5
0.5
1.0
0.5
4.0
0.5
0.5
0.5
4.5
0.5
0.5
0.5
3.5
0.5
0.5
0.5
3.0
0.5
0.5
0.5
2.0
0.0
0.5
0.5
4.5
0.0
0.0
0.5
2.5
Jul 2012
OUH Selfassessment
1a. Does quality drive the trust’s strategy?
1b. Is the Board sufficiently aware of potential risks to quality?
Capability and Culture
Strategy
Measurement
4a. Is appropriate quality information being analysed and challenged?
4b. Is the Board assured of the robustness of the quality information?
4c. Is quality information being used effectively?
Total
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Primary
QGF
Question
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.1
1a.2
1a.2
1a.2
1a.2
1a.2
1a.3
1a.3
1a.3
1a.3
1a.3
1a.3
1a.3
1a.3
1a.3
1a.3
1a.4
1a.4
1a.5
1a.5
1a.5
1a.6
1a.7
1a.7
1a.7
1a.7
1a.8
1a.8
1a.8
1b.1
1b.1
1b.1
1b.1
1b.1
1b.1
1b.1
1b.1
1b.1
1b.10
Appendix 2
Evidence Title
Annual Business Plan (s) Divisional
CEO and Team briefs
CQC Reports
Directorate quality posters
Integrated Business Plan
Minutes of Clinical Governance Committee
Minutes of Divisional meetings.
Performance Meeting letters
QIA for CIPS
Quality Account 14/15
Quality Committee Report
Quality Matters newsletter
Quality Reports (e.g. to Quality Committee)
Quality Strategy/ Implementation plan.
TME Papers updating progress with regard to peer review
TME Papers updating progress with regard to risk summits
Divisional quality Priorities
Divisional Quality Reports
Dr Foster reports and alerts
Integrated Performance report
National and local patient experience surveys & stakeholder events
Action Plans after Executive walk rounds plus examples of posters
Business Plans - Divisional
Contract Review Meeting Agenda
Corporate Risk Register Report
Dr Foster reports and alerts
Example of quality improvement initiatives
Minutes of patient engagement event on quality priorities
National Audit reports via web link in Intranet
Patient involvement groups - attended by board
Staff Surveys
Staff suggestion scheme
Stakeholder events
Divisional Governance Minutes
Outputs of ORBIT data warehouse
Quality Posters
Bi annual report to Board
Example emails global emails re quality
Intranet / Internet - Re Quality Updates
LIA Programme
OUH news
Board Minutes
Patient story programme for Board
Terms of Reference to Quality Committee - current version not
Annual Complaints Reports - timing
Attendance register demonstrating attendance by Board members re Risk summit
BAF and CRR Board papers
CIP template Divisional and Directorate Quality Posters (Examples of posters)
Examples of completed QIA
Outpatient re-profiling project
Patient story programme for Quality Committee
Terms of Reference Audit Committee
CIP information on Intranet
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Primary
QGF
Question
1b.10
1b.10
1b.10
1b.11
1b.11
1b.11
1b.3
1b.4
1b.6
1b.6
1b.7
1b.7
1b.7
1b.9
2a.1
2a.1
2a.1
2a.1
2a.1
2a.2
2a.2
2a.2
2a.3
2a.4
2a.4
2a.4
2a.5
2a.6
2b.1
2b.1
2b.1
2b.2
2b.2
2b.3
2b.3
2b.3
2b.6
2b.6
2b.6
2b.6
3a.1
3a.2
3a.4
3b.2
3b.2
3b.3
3b.3
3b.3
3b.3
3b.4
3b.5
3b.5
3b.5
3b.5
3b.5
3b.5
TB2015.61
Evidence Title
CIP process document.
CIP Report for Quality Committee
CIP summary sheet
Action taken from feedback - whistleblowing and raising concerns
CGC agendas
Workforce Committee Minutes
Examples of Divisional and Directorate Risk Registers
Minutes of TAG reported to Clinical Governance Committee
Business Planning Guidance
Example Business Cases
Endoscopy efficiency project
NPSA six monthly organisational incident
Template for business cases
Example of Service improvement project
Clinical Governance Committee minutes reported to Quality Committee
Infection Control Annual Report to Quality Committee
Internal Audit Plan
Prevention of Future Death Annual Report
Safeguarding Annual Report to Board
Board Development programme
Board membership breakdown and biographies
Example of Board Seminar Agenda
Report Update to Board on Cardiac Surgery
Discharge Improvement Plan
End of Life Business Case
End of Life Seminar
Board Report on Committee Effectiveness
Examples of Board Away Days
Clinical Governance Committee Terms of Reference
Healthcare for All Reports
Ombudsman (PHSO) summary reports
Obstetric investment
Supported Hospital Discharge Service
Patient Experience Strategy
PLACE reports to the Quality Committee
Quarter 4 OD & Workforce Performance Report
Series of service improvement team projects
Examples of committees monitoring action plans
Examples of service improvement projects at Divisional level
Minutes for TME
Divisional Executive Meetings (DME)
Board agenda
Effectiveness review reports
Incident reporting policy
Quality Committee SIRI paper(s)
Action plans from SIRIs
Cardiac action plan
Complaint action plans
Patient Safety and Clinical Risk Committee minutes
Examples of outputs from SIRI closure meetings
Annual Clinical Audit Report to Clinical Audit Committee
Annual Clinical Audit Report to Quality Committee
Clinical Audit Committee Terms of Reference
Clinical Audit Plan
Clinical Audit reports to Clinical Governance Committee
Internal Audit Reports to the Audit Committee
TB2015.61 Update on Quality Governance Framework
Page 13 of 14
Oxford University Hospitals
Primary
QGF
Question
3b.6
3b.6
3b.6
3b.8
3b.8
3b.9
3b.9
3b.9
3b.9
3c.1
3c.2
3c.2
3c.3
3c.5
3c.5
3c.5
4a.3
4a.4
4a.4
4a.4
4a.7
4a.7
4a.8
4a.8
4a.8
4b.2
4b.6
4b.6
4b.6
4b.6
4c.4
4c.4
TB2015.61
Evidence Title
Clinical Audit Procedure
Clinical Audit Strategy
Minutes of Clinical Audit Committee
Clinical Governance Organisational Structure
Staff Recognition schemes
Emergency Department Paediatric Transfer Protocol
Home for Lunch
Length of Stay project
Pharmacy project
Learning Disability Partnership Group
Board Reports (public)
Chief Executive briefings
Quarterly Complaints Report
DTOC groups
Health Overview and Scrutiny Committee
Maternity Services Liaison Committee
Committee Structure chart
Electronic patient record
Medical Appraisal Policy with local requirements
Minutes of coding meetings
Dr Foster reports to Clinical Governance Committee
Specialist Commissioning Dashboards
Data Quality Group Terms of Reference
Internal audit of quality of data
Minutes from Data Quality Group
Minutes of Divisional data quality groups
Annual External Audit PbR review
Clinical coding good practice guide
Clinical Coding top tips guide
Example minutes of coding meetings
Medicines reconciliation data
CQC Outlier information
TB2015.61 Update on Quality Governance Framework
Page 14 of 14