1. Introduction CLINICAL QUALITY GROUP CWHHE s Commissioning Collaborative: Terms of Reference The purpose of the Clinical Quality Group (CQG) is to enable membership drawn from both commissioners and providers to monitor areas of clinical quality together and to jointly identify areas for clinical service development and innovation. Clinical commissioners will expect the CQG to act as the key structured meeting to seek assurance in relation to specific areas of clinical quality. Although the CQG meetings will be commissioner led and managed a key expectation is that underpinning the CQG will be collaborative joint working between clinical commissioner and commissioned provider. The CQG will form a core part of assurance and quality improvement in relation to quality monitoring linked to contract management and performance. 2. Purpose of the group The purpose of the group is to ensure that there is a clear focus on quality linked closely to contract management. It will provide a creative space for critical analysis and development of joint solutions and learning to support improvements in patient safety, clinical effectiveness and patient experience. The group will make recommendations to the Performance & Contract Executive (PCE) however reporting, escalation and accountability will be to the respective Clinical Commissioning Group () Quality and Patient Safety Committee which are sub committees of the Governing Body. Any matters requiring contractual agreement will be referred to the PCE for action. Issues of significant quality and patient safety will be referred to the respective lead Quality and Patient Safety Committee. The work and focus of the CQG will take direction from the overarching quality strategy, quality schedule, CQUINS, national reports and monthly provider returns. The CQG also provides an opportunity for providers to show case areas of innovation, service improvements and notable successes. 3. Responsibilities The CQG acts as an expert committee that reports on and provides clinical advice as well as reviewing and managing the clinical quality and patient safety issues as defined by the annual contract and by any additional requirements as set by the Department of Health, the NHS England or relevant authority. The group will ensure that adequate information is made available to provide assurance of quality and safety; specifically the group will: Review provider compliance with the conditions of the contract that relate to the delivery of clinical quality. Review of the quality schedule (national & local) and the patient impact of the CQUIN schemes. This will be delivered by an agreed annual programme of work aligned to the Service Conditions, General Conditions & the Quality Schedule within the Particulars. CWHHE will produce an annual scheduler to ensure expectations are clearly communicated. 1
1. Standing Agenda Items All CQGs will have a standard format: Agenda Item Frequency Lead Apologies Minutes from the previous meeting Action Log Quality successes and notable service improvement projects Specific local areas for clinical discussion/ review/ concern Serious Incident Report inc. actions taken/ planned and themes / Performance (Quality Indicators) Commissioned provider Maternity Dashboard (only those Trusts that provide this Maternity Service) Cancer (only those Trusts that provide Cancer Services) Workforce (inc Safer Staffing, Appraisal and Vacancy and retention) Infection and Prevention CQUINS Drugs Advisory Committee (Imperial Healthcare NHS Trust only) Patient Experience (encompassing thematic analysis of themes and trends) eg Complaints & PALS, Friends and Family Safeguarding (Children and Adults), MCA, DoLS and Learning Disability Francis Inquiry plan/ update CIP 6 The CQG may choose to use the meeting (in part) to seek greater formative understanding/ deep dive into specific areas/ services within the Trust either linked to a standing agenda item or nonstanding agenda items such as Whole Systems and Out of Hospital Care. 5. Meeting Frequency The CQG will meet monthly or more frequently if deemed necessary at the discretion of the Chair but no less than 6 times per year. 2
Group members will reserve the right to arrange ad-hoc sub / working group meetings as required taking forward and preparing information for the formal monthly meetings. These groups will report back to the CQG e.g. CQUINS or CIP working groups. 6. Lead s Specific s will lead on CQG Meetings: Central London (CL) Ealing (supported by Hounslow and Hammersmith and Fulham s) Hammersmith & Fulham (H & F) Hounslow West London (WL) Central London Community Healthcare NHS Trust West London Mental Health Trust, Ealing ICO (community) Imperial College Healthcare NHS Trust West Middlesex University Hospitals Trust Hounslow and Richmond Community Healthcare Chelsea & Westminster NHS Foundation Trust 7. Membership of the CQG Core members 1 : Lead ( Clinical Commissioner) Chair representative (s) (Clinical Commissioner) Director of Quality, Nursing and Patient Safety/ Deputy Director of Quality, Nursing and Patient Safety/ Assistant Director of Quality Improvement and Clinical Assurance, CWHHE s (Clinical Commissioner) Lay Member/ Patient Representative (Commissioning) Deputy Chair Managing Director/ Deputy Managing Director (Commissioning) Specialist Commissioning (NHS England - London) Associates (Clinical Commissioner) LA Public Health Lead Contract Support Officer (Commissioning) minutes Director of Nursing and Quality () or Designate Medical Director () or Designate Chief Operating Officer/ Director of Operations () or Designate Clinical Governance Lead () Associate Director of Service Development () Imperial Healthcare NHS Trust only Service Development Manager () Imperial Healthcare NHS Trust only Attendance as required: 1 Associate commissioners (or OOA) are invited to and able to attend meetings if they wish, as well as receiving papers as a matter of routine. 3
Medical Director/ LAT Deputy Director of Nursing (NHS England - London) NTDA Quality Lead Designated Nurse for Safeguarding Children (Clinical Commissioner and Provider) Infection Control Lead (Clinical Commissioner and Provider) Safeguarding Adults Lead (Clinical Commissioner and Provider) Other clinicians or managers may be co-opted or invited to part or all of its meetings as required. 8. Quorum The quorum for the CQG shall be a minimum of two clinical commissioners along with three core members from the. 9. Decision making The CQG can request further assurance on the quality reports received by the group and recommend sign-off of CQUINS and CIPs. In order to sign-off achievement of a CQUIN milestone or CIP, the CQG or designated sub-group will need to achieve agreement from at least: Two representatives One senior commissioning lead related to the topic from the One lead for the commissioned provider 10. Meeting Arrangements The contract account team will manage and coordinate the CQG for the s. Group members must ensure that papers are sent to the meeting administrator at least seven working days prior to the CQG meeting, with papers being circulated a minimum of five working days prior to the meeting. Papers tabled at the meeting will not be accepted unless in exceptional circumstances and with approval of the chair. Minutes and an action log will be reviewed at the start of each meeting for agreement and corrections made. All members are expected to note actions relevant to them from the meeting and should not rely on draft minutes for noting actions. Outputs of the group will also be shared with the relevant commissioners and s in order to provide clear feedback to inform the quality and contract management processes. Actions requiring a response ie those that cannot wait until the next CQG, will be responded to within 5 working days following the CQG. Outputs of the group will also be shared with other s who commission services for their patients from the provider but are not represented on the membership These Terms of Reference will be changed as necessary by agreement of the CQG and will be reviewed at least annually. 4
Date approved: Review date: October 2015 5