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NHS Tayside

Improvement and Quality Sub-Committee

1. Introduction

This paper outlines the terms of reference for the Improvement and Quality Sub-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 Bill Mutch, Lead for Improvement and Ms Caroline Selkirk, Lead for Quality.

3. Support Officer

Items for the agenda should be submitted to the Committee Support Officer who is Miss Lynda Long, Corporate Services Officer.  She can be contacted via email at lynda.long@nhs.net or by phone at 01382 424076 (x71076).

4. Purpose of Committee

To provide the Improvement and Quality Committee of NHS Tayside with the assurance that: -

  • Effective mechanisms are in place throughout the local NHS system to support improvement;
  • The principles and standards of Partnerships for Care (2003) are applied to the improvement activities of NHS Tayside;
  • Clinical Governance mechanisms are in place and effective throughout the whole of the NHS system including health improvement activities;
  • A strategic framework for patient and public involvement is in place and to monitor and evaluate this;
  • Governance arrangements are in place for equality and diversity.

To provide the Delivery Unit Executive Group:-

With a monthly performance management report on process and recommend actions that will lead to improvement on the key areas identified.

5. Membership

Mr John Angus, Non-Executive Member, Tayside NHS Board
Mr Ian Wightman MBE, Non-Executive Member, Tayside NHS Board
Mr Alan Shepherd, Chair, Area Clinical Forum
Ms Caroline Selkirk, Director of Change and Innovation, Tayside NHS Board
Ms Margaret Simpson, Director of Nursing, Delivery Unit
Dr Bill Mutch, Medical Director, Tayside NHS Board

Regular Attendees

Mrs Muriel Anderson, Assistant Director of Finance, Delivery Unit
Ms Allyson Angus, Public Involvement Manager, NHS Tayside
Mr Alan Boyter, Director of Strategic Human Resources and Workforce Development, NHS Tayside
Mrs Gillian Costello, Head of Managed Clinical Networks, NHS Tayside
Mrs Margaret Donaldson, Public Partnership Group Representative from Perth & Kinross
Mr Ian Fenton, Head of ICT, NHS Tayside
Mrs Margaret Harper, Employee Director, NHS Tayside
Dr Iain Levack, Clinical Group Director – Critical Care, Delivery Unit
Mrs Carrie Marr, Associate Director Change and Innovation, Tayside NHS Board
Mrs Margaret Moulton, Board Secretary, Tayside NHS Board
Mr Daniel McLaren, Assistant Chief Executive, Tayside NHS Board
Mrs Arlene Napier, Clinical Governance Coordinator, NHS Tayside
Mrs Pat O’Connor, Head of Risk Management, NHS Tayside
Ms Ann Pearson, Head of Social Inclusion, NHS Tayside
Ms Wendy Peacock, Infection Control Manager, NHS Tayside
Dr Gabby Phillips, Infection Control, NHS Tayside
Ms Elaine Precious, Health Governance Coordinator, NHS Tayside
Dr Alistair Robertson, Clinical Group Director, Clinical Support Services, NHS Tayside
Mr Andy Russell, Director of Primary Care, NHS Tayside
Mrs Vanessa Shand, Area Partnership Forum Representative
Mr David Smith, Public Partnership Group Representative from Dundee
Dr Drew Walker, Director of Public Health, Tayside NHS Board

6. Quorum

Meetings will be quorate when two members are present one of whom will be a Non-Executive Board Member and one a clinical member.

7. Frequency of Meetings

Meetings are held 8  times per annum.

8. Remit

Performance management of:

  • Improvement and Quality Work Plan

    - All aspects of improvement and quality strategies

  • Delivering for Health

    - Overall progress
    - Unscheduled Care
    - Outpatients and diagnostics
    - Community Hospitals
    - Long Term Conditions

  • Major risk management projects

    - Patient Safety
    - Head of Risk Management to provide a list for agreement at the first meeting of the sub-group for agreement

  • Inequalities
  • Equality and Diversity
  • Inequalities Strategy
  • Prevention 2010
  • Managed Clinical Networks
  • Public Involvement
  • Public Health/Health Improvement

Each of the above will be considered by the Committee as part of a rolling programme.  This will be drawn up by the Sub-Committee and agreed by the Committee.

  • To approve the annual spiritual care implementation plan;
  • To approve the annual spiritual care report;
  • To receive and consider Taystat Action Notes from the Chairman’s Scrutiny Meeting and Chief Executive’s Performance Meeting;
  • To establish a Health Governance Group that will have the responsibility for ensuring that the principles and standards of improvement and clinical governance are applied to the health improvement activities of the Board.
  • To establish a Spiritual Care Forum which will have responsibility for providing advice on and a forum for developing NHS Tayside Spiritual Care Policy and overseeing its implementation.

9. Reporting Arrangements

  • The Improvement and Quality Sub-Committee reports to Delivery Unit Committee;
  • Following a meeting of the Improvement and Quality Sub-Committee the minutes of that meeting should be presented at the next Delivery Unit Committee and the Improvement and Quality Committee;
  • The Improvement and Quality Sub-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 Sub-Committee;
  • The Improvement and Quality Sub-Committee will produce and Annual Report for presentation to The Delivery Unit Committee and the Improvement and Quality Committee.  The Annual Report will describe the outcomes from the Sub-Committee during the year.

10. Work Plan

Improvement and Redesign

  1. The SDU Workplan will consist of a range of improvement work led through Specific Improvement Collaboration.  These local improvement collaborations will regularly report on their work to the Sub Committee
  2. NHS Tayside has been piloting rapid improvement methodology in partnership with the Scottish Executive Health Department and the outcome of this programme of events will be reported on.

Safety, Risk and Clinical Governance

Key progress in relation to :

  • QIS – Risk Management and Clinical Governance Standards Action Plan.
  • Health and Safety organisational workplan progress
  • Patient Safety programme, including National Patient Safety Alliance Progress.
  • Key local priorities for Safety, Governance and Risk (Standards and Guidelines, Reporting, Patient Focus Public Involvement, Patient Safety/Medicines Management, Learning and Development, Mental Health, Partnership Working, Risk Management, Capacity and Flow and Long Term Conditions)
  • Complaints and Claims – progress in response and key themes – management of claims.
  • Review of the key Risk Management activities, process and mitigation strategies.

NHS HDL (2004) 04 requires clinicians planning to undertake new interventional procedures to seek approval from their organisations Clinical Governance Committee before proceeding.  Within NHS Tayside this matter has been managed by the Improvement and Quality Sub-Committee and reports will continue to be submitted to the sub-committee throughout the year as required.

 Regular clinical governance reporting from the CHPs and Acute Services will form part of a rolling programme as follows:


30 April – Angus CHP
25 June – Secondary Care
13 August – Dundee CHP
24 September – Perth & Kinross CHP
12 November – Angus CHP
10 December – Secondary Care


28 January – Dundee CHP
10 march – Perth & Kinross CHP

As part of integrated Safety, Governance and Risk agenda – the lead officers will report key priorities to this committee. Priorities are as follows:

  • Partnership development and delivery
  • PFPI including patient information
  • Patient safety
  • HAI
  • Mental health
  • Compliance with National guidance/standards
  • Risk Assessment and management


Managed Clinical Networks

There will be a rolling programme for reporting service delivery and quality improvements through MCNs to ensure their accountability to NHS Tayside Board.  The agreed programme for 2007/08 is as follows;

30 April 2007 – Tayside Nutrition and Dietetic Services MCN
13 August 2007 – HEP C MCN
13 August 2007 – Addictions Services MCN
24 September 2007 – Brain Injuries Care Network
24 September 2007 – NMCN PHOTONET
12 November 2007 – Orthodontic Services MCN
12 November 2007 – NMCN Home Parenteral Nutrition
12 November 2007 – NMCN CLEFTSiS
10 December 2007 – CHD MCN
10 December 2007 – Cancer Services MCN
28 January 2008 – Stroke MCN
28 January 2008 – Respiratory MCN
10 March 2008 – Diabetes MCN
28 April 2008 – NMCN Complex Burns Care


Patient Focus Public Involvement

The Scottish Executive Spending Review  (2004) Target 3; provides that all NHS Boards are required to achieve year on year improvements in the involvement of the public in the planning and delivery of NHS services and in the involvement of patients in decisions about their health care and the development of services.  The Scottish Health Council has a duty to conduct an annual assessment of each Boards performance in Patient Focus Public Involvement (PFPI).

Year round reporting and assessment will be submitted to the Scottish Health Council through the PFPI Leads and Operational Group and will be submitted to the Improvement and Quality Sub Committee to coincide with these.


Health Governance &Health Inequalities

The sub-committee will review the revised governance arrangements for Public Health and to ensure that clear reporting mechanisms continue to be in place for public health governance.

The sub-committee will ensure that health inequalities are considered and addressed where possible.


Spiritual Care

The sub-committee will receive copies of all minutes of the spiritual care forum and an annual report from the forum and spiritual care department.



The sub-committee will regularly receive and consider reports and action points from the Taystat Chairs Scrutiny Meeting and Chief Executive’s Performance Meeting.


11.            Timetable for submitting agenda items and papers

Draft Reports
to be with Committee Support Officer
1200 hrs on:-


Draft Reports circulated to the agenda planning team for scrutiny before planning meeting


Agenda Planning with Chairman,
Lead Officers & Committee Support Officer
(all 12.30am)


Papers in final form
to be in the hands of Committee Support Officer by 1200 hrs on:-


to be issued on:-


Date of Meeting
(all 13.30 hours)


 6 April 2007

9 April 2007

16 April 2007

20 April 2007

23 April 2007

30 April 2007

 1 June 2007

4 June 2007

11 June 2007

15 June 2007

18 June 2007

25 June 2007

 20 July 2007

23 July 2007

30 July 2007

3 August 2007

6 August 2007

13 August 2007

 31 August 2007

3 September 07

10 September 2007

14 September 2007

17 September 2007

24 September 2007

 19 October 2007

22 October 2007

29 October 2007

2 November 2007

5 November 2007

12 November 2007

 16 November 07

19 November 07

26 November 2007

30 November 2007

3 December 2007

10 December 2007

 4 January 2008

7 January 2008

14 January 2008

18 January 2008

21 January 2008

28 January 2008

 15 February 08

18 February 2008

25 February 2008

29 February 2008

3 March 2008

10 March 2008

 4 April 2008

7 April 2008

14 April 2008

18 April 2008

21 April 2008

28 April 2008

 16 May 2008

19 May 2008

26 May 2008

30 May 2008

2 June 2008

9 June 2008

 18 July 2008

21 July 2008

28 July 2008

1 August 2008

4 August 2008

11 August 2008

 29 August 2008

1 September 08

8 September 2008

12 September 2008

15 September 2008

22 September 2008

 10 October 2008

13 October 2008

20 October 2008

24 October 2008

27 October 2008

3 November 2008

 28 November 08

1 December 2008

8 December 2008

12 December 2008

15 December 2008

22 December 2008

Chairman –Mr Ian Wightman 
Vice-Chair – Mr John Angus
Lead Officers – Dr Bill Mutch/ Ms Caroline Selkirk
Committee Support Officer - Lynda Long: Email lynda.long@nhs.net: Call 01382 424076: Internal x71076

All Sub-Committee Meetings are held in the Seminar or Board Room, King’s Cross at 1.30pm.
All agenda planning meetings are held in the Sidlaw Room, King’s Cross at 12.30am.



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Contact Us: Tayside NHS Board , NHS Tayside Headquarters, Ninewells Hospital & Medical School, Dundee, DD1 9SY
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