Quality & Risk Committee (QRC) Terms of Reference

Transcription

1 Approved by the Board 27 th August Introduction Quality & Risk Committee (QRC) Terms of Reference 1.1 The Quality & Risk Committee is a formally constituted committee of the Trust Board (the Board) created to provide assurance and make recommendations in matters relating to clinical quality and standards, and to ensure that risks to the delivery of the Trust s services are identified and addressed. 2. Constitution 2.1 The Board hereby resolves to establish a committee of the Board to be known as the Quality & Risk Committee (The Committee). 2.2 The Committee is a time limited committee of the Board. The function and scope of the Committee against these terms of reference will be reviewed annually. Following review the Board may dissolve the Committee. 2.3 The Committee only has delegated powers when specifically granted by the Board. 3. Membership 3.1 The Committee shall be appointed by the Board from the Non- Executive and Executive Directors of the Trust. It shall consist of not less than six members and shall include: The Medical Director The Executive Director of the Patient Experience and Nursing The Chief Operating Officer At least three Non-Executive Directors 3.2 A quorum shall be three members, one of whom must be a Non- Executive Director together with either the Medical Director, the Executive Director of the Patient Experience and Nursing or the Chief Operating Officer. Given the Committee s status as a Committee of the Board, it is expected that members should make every effort to attend Committee meetings and will attend every meeting unless there are good reasons preventing attendance. 3.3 The Board will appoint one of the Non-Executive Directors as Chair of the Committee. Page 1 of 5

2 4. Attendance 4.1 Other Executive Directors and senior managers may also be invited to attend to cover specific agenda items. All Executive Directors will usually attend during the review of the corporate risk register. 4.2 The Deputy Director of Nursing and Integrated Governance and the Assistant Directors of Health & Safety and of Governance and Quality Standards shall attend to assist in feeding information up and down the organisation regarding risk management. This includes reporting back through the organisation following QRC meetings. 4.3 The Trust Secretary shall ensure that the Committee is appropriately supported and that minutes are taken. 5. Frequency 5.1 The Committee shall usually meet four times a year. 6. Authority 6.1 The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary. 7. Duties 7.1 The duties of the Committee can be categorised as follows: Clinical Quality and Standards Receive a presentation from each of the clinical divisions on a quarterly rolling programme which outlines performance in relation to the clinical governance and quality agenda and what arrangements they have put in place to make any necessary improvements Review and challenge clinical quality and patient safety key performance indicators, and ensure that action plans are developed and implemented to address any areas of concern Make recommendations to the Board on the strategic direction for clinical quality and care, taking into account gaps in the Trust s performance, best practice, and relevant publications Review and challenge information on complaints, incidents, litigation, and concerns raised through the patient advice & liaison service (PALS) in order to receive assurance that any trends have been addressed and that the appropriate lessons have been learnt. Page 2 of 5

3 7.1.5 Monitor the Trust s compliance with Care Quality Commission registration requirements, and ensure that action plans are developed and implemented to strengthen practice where required Monitor the Trust s implementation of Central Alert Systems, and ensure any areas of non-compliance are entered onto the risk register as appropriate Consider any externally commissioned reports and ensure that action plans are developed and implemented to strengthen practice where required Oversee the development of the Clinical Quality Strategy and monitor progress of Trust-wide action plan Oversee the production of the Annual Quality Report (Quality Accounts), recommend the priorities for quality improvement to the Board for approval, and monitor the delivery of such priorities Approve the Clinical Audit work programme, and monitor the key risks arising from clinical audits and the actions to address them Review NICE guidance compliance and ensure that action plans are in place to address non-compliance and where this cannot be achieved that relevant risk assessment is undertaken Ensure that a sub-committee structure is in place beneath the Board to oversee clinical quality and governance; and receive reports from these key groups (including but not necessarily limited to): Clinical Governance Committee Infection Control Committee Medical Education Faculty Board Experience and Engagement Group (EEG) Clinical Audit & Effectiveness Committee Safeguarding Committee Dementia Steering Group Cancer Board Maternity Board Health and Safety Committee Ensure that action plans developed to improve clinical quality are carried out in a timely fashion. Risk management For all high and medium risks on the corporate risk register review, challenge, and agree the mitigating actions and the Executive Director accountable for ensuring these are implemented to reduce or eliminate the risk in a timely manner. Page 3 of 5

4 Ensure that any areas of concern identified from the Committee s review of clinical quality are entered into the risk register, as appropriate Ensure that gaps in control identified on the Board Assurance framework appear on the risk register, as appropriate Assess the impact of risks present in one area of the Trust for impact on other areas of the Trust. Where risks cross organisational boundaries e.g. Mount Vernon, ensure that effective risk management systems and processes are in place and operating effectively Provide assurance to the Audit & Assurance Committee that risks identified on the corporate risk register are referenced in the Board Assurance Framework should these be a risk to achievement of the Trust s strategic objectives. (NB The Audit & Assurance Committee is the lead Committee for overseeing the Board Assurance Framework.) 8. Reporting 8.1 Agenda and papers of the Committee meetings will be circulated no less than five working days prior to the meeting. 8.2 The minutes of the Committee meetings shall be formally recorded, and the Chair of the Committee shall draw to the attention of the Board any issues that require the attention of the full Board. 8.3 All high risks will be reported to the Board at least four times a year. 8.4 Reporting of risks to the Committee from lower levels in the organisation is carried out using the online risk register actions and progress updates; and the attendance at the meeting of the Deputy Director of Nursing and Integrated Governance, and the Assistant Directors of Corporate Governance and Quality Standards and of Health & Safety. 9. Other Matters 9.1 The Trust Secretary shall ensure that the Committee has administrative support, which will include: Agreement of agenda with Chairman and attendees and collation of papers Organising the attendance of appropriate persons to meetings (other than those who would usually attend) Taking the minutes and keeping a record of matters arising and issues/ actions to be carried forward Advising the Committee on pertinent matters. Page 4 of 5

5 9.2 The Committee will review its effectiveness and compliance with these terms of reference each year, and report the outcomes of this review to the Board. Page 5 of 5