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TERMS OF REFERENCE AND WORKPLAN 2013 - 2014
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:
3. Support Officer
Items for the agenda should be submitted to the Committee Support Officer , Alison Hodge, who can be contacted via e-mail at firstname.lastname@example.org or by phone on 01382 740761 (ext 40761).
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.
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.
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
To provide assurance regarding participation, patient rights and feedback. The committee will establish:
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:
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 endorse all clinical Policies to include Infection Control, Nursing and Midwifery and Medicines Policies.
The Committee will receive a Bi-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.
Professional Development and Management
To ensure that staff governance issues which impact on service delivery and quality of
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
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.
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.
The Committee will receive an annual report relating to the quality of research processes in Tayside.
The Committee will receive an annual report to provide assurance on the implementation of the UK Organ Donor Taskforce recommendations from its established Organ Donation Committee.
7. Best Value
The Committee is responsible for reviewing those aspects of the Best Value work plan which are delegated to it from NHS Tayside Board. The Committee will put in place the arrangements which will provide assurance to the Chief Executive as Accountable Officer, that NHS Tayside has systems and [processes in place to secure best value for these delegated areas. The assurance to the Chief Executive should be included as an explicit statement from the Committee’s Annual Report.
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 2013-14
Chairperson – Mrs Alison Rogers