North Middlesex University Hospital NHS Trust
RISK AND QUALITY COMMITTEE
TERMS OF REFERENCE
Version:
1.0
Ratified by:
Trust Board
Date ratified:
July 2013
Name of originator/author:
Board Secretary
Name of responsible committee:
Risk and Quality Committee
Name of executive lead:
Director of Nursing
Date issued:
August 2013
Review date:
August 2014
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RISK AND QUALITY COMMITTEE
TERMS OF REFERENCE
1
AUTHORITY
1.1
The Risk and Quality Committee is constituted as a Standing
Committee of the Board. Its Constitution and Terms of Reference shall
be as set out below, subject to amendment by the Board.
1.2
The Committee derives its powers from the Board and has no
executive powers, other than those specifically delegated in these
Terms of Reference.
1.3
The Committee is authorised by the Board to investigate any activity
within its Terms of Reference. It is authorised to seek any information it
requires from any member of staff and all members of staff are directed
to co-operate with any request made by the Committee.
1.4
The Committee is authorised by the Board to request the attendance of
individuals and authorities from outside the Trust with relevant
experience and expertise if it considers this necessary.
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PURPOSE
2.1
The Trust Board is responsible for ensuring robust structures and
processes are in place for governing the quality of clinical services and
ensuring services are safe.
2.2
The Risk and Quality Committee’s primary role is to provide assurance
to the Board on Clinical Quality & Safety, including Clinical
Effectiveness, Patient Safety and Patient Experience utilising best
practice metrics that provide robust clinical governance processes to
deliver safe, high quality and patient centred care.
2.3
Specifically, the Committee will:
2.4
Monitor the Trust’s compliance
requirements:
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2.5
with
statutory and
regulatory
Care Quality Commission regulations
Information Governance Toolkit
NHS Constitution
NHSLA
Equality Act 2010
Best practice guidance including NICE guidance
Health and Safety at Work Act 1974.
Oversee the development and implementation of the Quality strategy,
as well as the Trust’s achievement of quality indicators, including the
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Quality Accounts declaration.
2.6
To seek assurance that the essential standards of quality and safety
(as determined by CQC’s registration requirements) are at a minimum
being met by every service that the organisation delivers.
2.7
To ensure that the organisation is striving for continuous quality
improvement and outcomes.
2.8
Seek assurance on the Trust’s arrangements for ensuring the best
possible clinical outcomes are achieved for patients, whilst monitoring
any areas where improvements are required.
2.9
Monitor the Trust’s arrangements for ensuring patients’ views and
feedback are captured and where relevant incorporated within service
improvements.
Monitor the implementation of action plans associated with serious
untoward incidents, high risk incidents, serious case reviews and
complaints. As part of this process, the Committee will scrutinise and
challenge the effectiveness of the Trust’s arrangements for
disseminating and implementing learning at Trust level, whilst
reviewing assurance on its effectiveness, such as the Francis and
Keogh Report.
2.10
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MEMBERSHIP
3.1
Members of the committee shall be appointed by the Board and shall
include two Non Executive Directors of the Board, a patient
representative ( and a governor once governors are in place) and
senior management consisting of:
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Director of Nursing
Medical Director
Director of Operations
Head of integrated Governance
Associate Medical Directors
3.2
The Committee will be chaired by a Non-Executive Director.
3.3
The Committee will ensure that the patient experience is a core focus
of its remit and agenda and will seek a patient representative (and a
governor, when appropriate) as a formal Committee Member to provide
challenge and assurances that the Committee is addressing the
required improvement areas.
3.4
Appointments to the Committee shall be for a period of up to three
years, which may be extended for a further three year period, provided
the non-executive director concerned remains a member of the Board.
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4
REPORTING RESPONSIBILITIES
4.1
The Committee Chair shall report formally to the Board on its
proceedings after each meeting on all matters within its duties and
responsibilities.
4.2
The Committee shall make whatever recommendations to the Board it
deems appropriate on any area within its remit where action or
improvement is needed.
4.3
The Committee shall oversee the production of an annual report to the
Board.
4.4
The Committee shall make available upon request, in a format they
deem appropriate, information regarding the attendance of all members
at committee meetings.
4.5
The Committee will ensure its groups operate effectively and discharge
their roles appropriately through quarterly assurance reports and an
annual review of their Terms of Reference. The following groups will
report to the Risk and Quality Committee:
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Clinical Effectiveness and Outcomes Group
Patient Experience Group
Risk and Safety Group
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QUORUM
5.1
To ensure the effectiveness of the Committee, the Quorum necessary
for the transaction of business shall be four members two of which will
include:
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The Medical Director/designated deputy
One Non Executive Director
OR
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Director/designated deputy
One Non Executive Director.
5.2
A duly convened meeting of the Committee at which a quorum is
present shall be competent to exercise all or any of the authorities,
powers and discretions vested in or exercisable by the Committee.
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FREQUENCY OF MEETINGS
6.1
The Committee shall meet on a bi-monthly basis and otherwise as
required. The Chair may request an additional meeting if this is
considered that one is necessary.
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NOTICE OF MEETINGS
7.1
The Board Secretary shall undertake the role of Secretary for the
Committee.
7.2
Meetings of the committee shall be summoned by the Secretary of the
committee at the request of any of its members, subject to the Chairs
approval.
7.3
Unless otherwise agreed, notice of each meeting confirming the venue,
time and date together with an agenda of items to be discussed, shall
be forwarded to each member of the committee, any other person
required to attend and all other non-executive directors, no later than
five working days before the date of the meeting. Supporting papers
shall be sent to committee members and to other attendees as
appropriate, at the same time.
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MINUTES OF MEETINGS
8.1
The Secretary shall minute the proceedings of all meetings of the
committee, including recording the names of those present and in
attendance.
8.2
The Secretary shall ascertain, at the beginning of each meeting, the
existence of any conflicts of interest and minute them accordingly.
8.3
Draft minutes of committee meetings shall be circulated promptly to all
members of the committee and, once finalised they will be submitted to
the Board.
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DUTIES
9.1
The duties of the Committee can be categorised as follows:
9.2
Quality
9.2.1 To oversee the development and implementation of the Quality
Strategy and associated policies and action plans.
9.2.2 To oversee the organisation’s processes for developing
implementing the quality improvement priorities, including:
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and
Monitoring of performance against the related quality
indicators
Overseeing assurance arrangements for the annual
Quality Account declaration.
9.2.3 Seek assurance on the Trust’s arrangements for actively engaging
patients, staff and key stakeholders on quality, including their patient
experience.
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9.2.4 Oversee the implementation of quality initiatives, such as High Quality
Care for all, whilst monitoring the compliance of the Trust with national
and local quality indicators.
9.2.5 Monitor the Trust’s plans for mitigating risks to quality associated with
financial and operational initiatives, (such as major service changes,
cost improvement plans) whilst ensuring the standards of clinical care
are maintained.
9.2.6 To oversee the Trust’s arrangements for maintaining compliance with
the Equality Act 2010 requirements including:
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9.3
Undertaking of Equality Impact Assessments
Monitoring of the Equality and Diversity Action Plan
The maintenance of a Single Equality Scheme.
Patient Safety
9.3.1 To oversee the Trust’s arrangements for meeting all regulatory and
mandated care standards, with robust response and tracking
processes in place to meet national alert requirements, national
guidelines and relevant external quality and safety standards with a
focus on agreed patient sensitive indicators.
9.3.2 To receive an agreed level of patient safety and outcomes data which
provides trends and themes from care delivery, utilising clinical metrics
to uniform and analyse the range of clinical services across the Trust.
9.3.3 To inform the Board about the level of assurance or risks on the
standards of care provided across the range of services, including
actions in place to drive improvements and mitigate risks.
9.3.4 To oversee the organisation’s arrangements for maintaining
compliance with the Care Quality Commission’s essential standards of
Quality and Safety.
9.3.5 To receive and review the annual Patient Safety report.
9.3.6 To receive and review the annual Health and Safety report.
9.4
Incident Reporting and Investigation
9.4.1 To monitor the effectiveness of the Trust's systems for reporting and
investigating Serious Incidents (SIs), near misses and high risk
incidents.
9.4.2 To review the outcomes of investigations and external inspections,
ensuring that the information is presented in sufficient detail to enable
systemic failings in patient care to be identified and mitigated in future.
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9.4.3 To monitor and receive assurance on action plans and progress
reports proposed by management in response to SIs, near misses and
other incidents.
9.5
Patient Experience
9.5.1 To ensure the organisation meets all its statutory and regulatory
obligations in relation to patient experience such as the NHS
Constitution rights and pledges of patients.
9.5.2 To oversee the Trust’s programme of patient surveys, and commission
additional surveys where further assurance is required.
9.5.3 To monitor the implementation of agreed actions/improvements
required to improve the patient experience.
9.5.4 To monitor the effectiveness of the Trust's systems for complaints
handling, monitoring the effectiveness of the Trust’s system for
advocacy and the encouragement of feedback from patients and
relatives.
9.5.5 To monitor patient complaints trends, and the implementation of action
plans arising from them, including a review of the Annual Complaints
report.
9.5.6 To oversee and monitor action plans resulting from patient surveys.
9.6
Clinical Effectiveness
9.6.1 To receive assurances on the effectiveness of clinical practice through
national audits and other external clinical reviews.
9.6.2 To review the effectiveness of the Trust's arrangements for the
systematic monitoring of national and local quality indicators, as well as
mortality and other patient outcomes.
9.6.3 To approve the annual clinical audit programme and the annual clinical
audit report.
9.6.4 To review key clinical audit findings and the action plans proposed by
management in response to these.
9.6.5 To commission clinical audits where required to provide additional
assurance.
9.6.6 To monitor the implementation of Research and Development
initiatives and to receive the Research and Development Annual
Report.
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9.6.7 To approve deviation from NICE Guidance where it is deemed
appropriate and necessary to do so.
9.7
Information Governance
9.7.1 To monitor the Trust’s arrangements for complying with statutory and
regulatory obligations stemming from the Data Protection Act 1998 and
Freedom of Information Act 2000.
9.7.2 To seek ongoing assurance on the Trust’s information risk
management arrangements through the Senior Information Risk
Owner.
9.7.3 To oversee the implementation of action plans associated with the high
risk information governance incidents or Serious Untoward Incidents.
9.7.4 To monitor the implementation of the Information Governance Action
Plan, ensuring the Trust meets a minimum compliance level 2 on the
Information Governance Toolkit.
9.8
Risk Management and policy oversight
9.8.1 To oversee the implementation of action plans associated with high risk
incidents and SIs, whilst monitoring the arrangements in place to
ensure any related risks are mitigated to an acceptable level.
9.8.2 To monitor compliance with regulatory requirements such as the
NHSLA Risk Management Standards.
9.8.3 To ensure the Trust’s risk management process is live in relation to
clinical risk, through the escalation of risks from the Directorate level
risk registers to the corporate risk register. In undertaking this role, the
Committee will seek assurance from the Risk and Safety Group, whilst
maintaining oversight of significant risks via a review of the corporate
risk register.
9.8.4 To undertake quarterly monitoring of the Board Assurance Framework
in relation to clinical risk. The Committee will review and assess the
adequacy of the risk mitigation plans against significant clinical risk.
9.8.5 The Committee will approve policies on behalf of the Board that fall
within its remit, advising the Board of any ratifications through the
Chair’s assurance report.
9.8.6 Areas that the Committee will be responsible for providing the Board
with assurance in relation to include:
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Clinical Governance
Research and Development Governance
Management of non financial risk (e.g. Emergency Planning)
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9.9
Legislative and regulatory compliance
Accreditation and assessment (e.g.
Commission regulations, NHSLA)
Policy Management Framework
Data quality.
the
Care
Quality
Managing Risks to Quality
9.9.1 In undertaking its role as Quality Committee of the Trust, the Risk and
Quality Committee will assess the effectiveness of the organisation’s
arrangements for managing risks to quality, taking assurance from the
work of the Risk and Safety Group where appropriate.
9.9.2 Reviewing the learning from complaints (upheld and non‐upheld)
following a Health Service Ombudsman investigation where
recommendations have been made for systemic improvements.
9.9.3 Ensuring the Trust acts on learning from HM Coroner’s Inquest and
specifically on Rule 43 decision.
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MONITORING EFFECTIVENESS
10.1
The constitution, Terms of Reference and progress of the Committee
shall be reviewed annually, or revised as part of the Trust’s progression
to Foundation Trust status.
10.2
The Committee will review its own performance and Terms of
Reference to ensure it is operating at maximum effectiveness and
recommend any changes it considers necessary to the Board for
approval, on an annual basis.
10.3
The Committee will establish an annual work programme which will be
submitted to the Board for approval as part of the assurance
arrangements.
10.4
In particular, the annual programme coverage will incorporate all key
areas within the Committee’s duties, as set out in section 9 of its Terms
of Reference.
10.5
The Committee will receive the annual workplans of its groups, and
assurance updates on progress quarterly
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