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NHS Tayside

Improvement and Quality Committee


TERMS OF REFERENCE AND WORKPLAN 2014 - 2015

1. Introduction

This paper outlines the terms of reference for the Improvement and Quality Committee (as approved by the Board, and contained within the NHS Tayside Code of Corporate Governance and the Committee’s Work Plan.

2. Executive Lead Officer

The executive lead officers for this committee are Dr Andrew Russell, Executive Lead for Quality, Safety and Clinical Governance and Dr Margaret McGuire, Executive Lead for Person Centred Care.

3. Support Officer

Items for the agenda should be submitted to the Committee Support Officer who is Alison Hodge, Committee Support Officer who can be contacted via e-mail at alisonhodge@nhs.net or by phone on 01382 740761 (ext 40761).

4. Purpose

To provide Tayside NHS Board with the assurance that robust governance and management systems and processes are in place and effective throughout NHS Tayside in areas detailed within the remit section.

5. Composition

Membership
  • A minimum of six Non-Executive Members including the Chair of the Area Partnership Forum (Employee Director) and the Chair of the Area Clinical Forum
  • Chief Executive
  • Medical Director (Lead Officer for Clinical Governance)
  • Nurse Director
  • Director of Public Health
In attendance
  • Deputy Chief Executive
  • Board Secretary
  • Vice Principal of the Medical School, University of Dundee
  • Representative of University of Dundee School of Nursing and Midwifery
  • Public Involvement Manager

6. Meetings

Meetings of the Committees will be quorate when at least five Members are present, at least three of whom should be Non-Executive Members of NHS Tayside.

7. Remit

To provide Tayside NHS Board with the assurance that robust governance and management systems and processes are in place and effective throughout NHS Tayside in the following areas

Person Centred

To provide assurance regarding participation, patient rights and feedback. The committee will establish:

  • A Person Centred Delivery Board with the remit to provide assurance; that there are effective systems and processes in place across NHS Tayside to support participation with patients and communities, to comply with participation standards and the Patient Rights (Scotland) Act 2011 generally and specifically within the context of service redesign. 
  • An Equality and Diversity Steering Group with the remit to provide assurance that NHS Tayside is complying with the Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 and to provide assurance that robust equality and diversity systems and processes are in place and effective throughout NHS Tayside.

The assurances from the Person Centred Delivery Board and Equality and Diversity Steering Group will be provided through the agreement of a work plan within the first quarter of the financial year and the submission to the Committee of a mid-year and an annual report.

Safe (Clinical Risk Management)  

To provide assurance in respect of clinical risk management arrangements by seeking assurance that there are adequate systems and processes in place across NHS Tayside to ensure that:

  • Robust clinical control frameworks are in place for the effective management of clinical risk and that they are working effectively across the whole of NHS Tayside.
  • Incident management and reporting is in place and lessons are learned from adverse events and near misses.
  • Complaints are handled in accordance with national guidance and lessons are learned from their investigation and resolution including reports of the Scottish Public Services Ombudsman and the Mental Welfare Commission.
  • Clinical standards and patient safety are not compromised within the Board’s annual efficiency programme which is Steps to Better Healthcare and that the financial and capital frameworks support the clinical strategy. 
  • Clinical dashboards and other data and measurement systems underpin the delivery of care.

The Committee will establish a Clinical Quality Forum (CQF) to provide these assurances through minutes and reports, incident management reports, complaints reports, national and local clinical data, minutes and reports from the Steps to Better Healthcare Programme Board. 

The Committee will adopt all clinical Policies to include Infection Control, Nursing and Midwifery and Medicines Policies.

The Committee will receive an annual report from risk owners with corporate risks aligned to the Committee.

Effective (Clinical Performance and Public Health Performance and Evaluation)

To provide assurance that clinical effectiveness and quality improvement arrangements are in place.  The Committee will establish a Clinical Quality Forum and a Public Health Governance Committee.

  • There is compliance with national standards for quality and safety.  These assurances should be provided through the agreement of a work plan within the first quarter of the financial year, receipt of action notes a midyear reports and annual report
  • Where results of inspection are below required standards, appropriate action plans will be developed and monitored by the Clinical Quality Forum or the Public Health Governance Group and reported to the Committee
  • Through the clinical audit function, the Committee will receive reports on the effectiveness of controls in place to mitigate against clinical risk
  • Where performance improvement is necessary within NHS Tayside, the Committee will approve appropriate improvement intervention and seek assurance regarding the reliability of the improvement intervention

Professional Development and Management

To ensure that staff governance issues which impact on service delivery and quality of
services are appropriately managed through clinical governance mechanisms and effective training and development is in place for all staff.

To provide assurance that governance arrangements for Research and Development are in place and effective the Committee will receive an annual report relating to the quality of research and processes within NHS Tayside.

The Committee will receive an Annual Report from the Clinical Academic and Professional Collaborative Committee

Improvement

To gain assurance on the application of improvement methodologies in NHS Tayside the Committee should review the work of the Tayside Centre for Organisational Effectiveness (TCOE) to ensure that there are adequate systems and process in place throughout NHS Tayside to meet capacity and capability priorities in this area.

The Committee will receive this assurance through the agreement of a prioritised work plan within the first quarter of the financial year, a mid-year and an annual report. 

Organ Donation

To provide assurance on the framework for the ethical and legal implications of organ donation in NHS Tayside, an Organ Donation Committee will be established.  The Committee will receive an annual report from the Organ Donation Committee.

8.  Authority

The Improvement and Quality Committee is accountable to NHS Tayside Board and as such is authorised by the Board to approve Safety, Clinical Governance and Improvement within its terms of reference, and in doing so is authorised to seek any information it requires in this area.

In order to fulfil its remit, the Improvement and Quality Committee may obtain whatever professional advice it requires, and require Directors or other officers of NHS Tayside bodies to attend meetings.

9. Reporting Arrangements

The Improvement and Quality Committee reports to Tayside NHS Board.

Following a meeting of the Improvement and Quality Committee the minutes of that meeting should be presented at the next Tayside NHS Board meeting.

The Improvement and Quality Committee should annually and within three months of the start of the financial year provide a work plan detailing the work to be taken forward by the Improvement and Quality Committee.

The Improvement and Quality Committee will produce an annual report for presentation to the Audit Committee.  The Annual Report will describe the outcomes from the Committee during the year and provide an assurance to the Audit Committee that the Committee has met its remit during the year.  The Annual Report must be approved by the Improvement and Quality Committee before it is presented to the Audit Committee considering the Annual Accounts.

 
IMPROVEMENT AND QUALITY COMMITTEE

SCHEDULE OF MEETINGS 2014-15

Draft Reports by: Agenda Planning Meeting Final Reports by: Agenda and Papers to be issued: Date of Committee Meeting

14 March 2014

17 March 2014

1 April 2014

3 April 2014

Thursday 10 April 2014
1:30 – 5pm
Board Room, Kings Cross

16 May 2014

20 May 2014

3 June 2014

5 June 2014

Thursday 12 June 2014
1:30 - 5pm
Board Room, Kings Cross

18 July 2014

21 July 2014

5 August 2014

7 August 2014

Thursday 14 August 2014
1:30 - 5pm
Board Room, Kings Cross

12 September 2014

15 September 2014

30 September 2014

2 October 2014

Thursday 9 October 2014
1:30 – 5pm
Board Room, Kings Cross

14 November 2014

17 November 2014

2 December 2014

4 December 2014

Thursday 11 December 2014
1:30 – 5pm
Board Room, Kings Cross

16 January 2015

19 January 2015

3 February 2015

5 February 2015

Thursday 12 February 2015
1:30 – 5pm
Board Room, Kings Cross

 

 

 

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Contact Us: Tayside NHS Board , NHS Tayside Headquarters, Ninewells Hospital & Medical School, Dundee, DD1 9SY
Telephone 01382 660111 or email contacts

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