INTEGRATED GOVERNANCE FRAMEWORK
Table of Contents
1. INTRODUCTION ... 3
2. STRATEGIC OBJECTIVES ... 4
3. SCOPE OF THE INTEGRATED GOVERNANCE FRAMEWORK ... 4
3.1 Definitions of Governance ... 4
3.2 The Role of the Board ... 4
3.3 Standing Orders and Standing Financial Instructions ... 5
3.4 Risk Management Strategy & Board Assurance Framework ... 5
3.5 Demonstrating Quality ... 6
3.6 Financial Governance ... 6
3.7 Information Governance ... 7
4. ROLE OF THE TRUST BOARD AND ITS SUB-COMMITTEES ... 7
4.1 Audit Committee ... 12
4.2 Governance ... 12
4.3 Trust Management Committee (Governance) - TMC(G) ... 12
4.4 Clinical Cabinet ... 13
4.5 Charitable Funds Committee ... 13
4.6 Remuneration Committee ... 13
4.7 Finance and Performance Committee ... 13
5 OTHER PRINCIPAL COMMITTEES AND GROUPS ... 14
5.1 Integrated Performance Management Framework ... 14
5.2 Risk Management Committee ... 15
5.3 Governance Work Stream groups ... 15
5.4 Divisional Quality & Learning Group ... 16
6. ARRANGEMENTS FOR PARTNERSHIP WORKING ... 16
6.1 Our community and our partners ... 17
7. DIVISIONAL GOVERNANCE ARRANGEMENTS ... 17
7.1 Divisional Management Teams... 18
7.2 Divisional governance ... 18
7.3 Quality Assurance in Divisions... 18
8. INTEGRATED GOVERNANCE SUPPORT ... 19
9. MONITORING AND REPORTING PROCESS ... 21
10. Equality and Diversity ... 21
10.1 Equality Impact Assessment ... 21
APPENDIX 1 – TRUST MANAGEMENT COMMITTEE (GOVERNANCE) 2014 WORK SCHEDULE ... 22
APPENDIX 2. GOVERNANCE INFORMATION ... 23
1. INTRODUCTION
Integrated Governance is the means by which an organisation pulls together all the competing pressures on the Trust Board and its supporting structures, to enable good governance and the delivery the organisation’s objectives.
The framework, systems and policies that underpin Integrated Governance ensure gaps in assurance are identified and minimised.
The Royal Cornwall Hospitals NHS Trust (RCHT) is committed to implementing the principles of good governance. This framework sets out to describe the system of integrated governance operated within the Trust. The framework is designed to ensure the delivery of high quality patient focussed care from an organisation that is well managed, cost effective and has a well trained and motivated work force. It will support the Trust’s application for Foundation Trust status and has been revised to reflect the latest changes in quality governance arrangements;
• Care Quality Commission Registration Regulations effective 1 April 2010 • Quality Governance in the NHS – March 2011 - A guide for provider boards –
National Quality Board
• The Healthy NHS Board 2013 – Principles for Good Governance
• Good Governance Handbook – 2012 – The Good Governance Institute And considers in shadow form;
• The NHS Foundation Trust Code of Governance - July 2010 - Monitor
This framework describes the high level integrated governance, risk management, performance management and financial control arrangements in place to support the Board in its management of the organisation. It is through this framework that the Trust provides robust evidence, through its governance and assurance framework, to demonstrate its compliance with the necessary quality and safety standards relevant to an NHS provider organisation.
This framework should therefore be considered alongside other key documents: • The Trust’s Risk Management Strategy and Policy provides a framework for the
management of the risks to achieving the Trust’s strategic aims and objectives. The strategy and policy are designed to establish a consistent and integrated approach to the management of all risk across the whole Trust. The framework takes account of the control and management of patient safety risks, organisational risk and financial risk.
• The Trust’s corporate procedure: Registration with the Care Quality Commission
Meeting the Essential Standards and Outcomes of Quality and Safety (June 2010) describes the Trust’s governance arrangements that will enable the Trust
2. STRATEGIC OBJECTIVES
The Trust’s strategic objectives are set out in its strategy, published annually. Underpinning delivery of these objectives, there is an integrated business planning process with business plans being produced for each division and corporate area before the beginning of each financial year.
3. SCOPE OF THE INTEGRATED GOVERNANCE
FRAMEWORK
Integrated Governance is based on the understanding that, although all elements of governance are important, they should not be managed in silos. To achieve focused decision-making and deliver strategic objectives, a Board needs to consider all aspects of accountability in the round. This framework considers the principal strands of governance common to NHS provider organisations and describes how the Royal Cornwall Hospitals Trust’s governance arrangements bring these together.
3.1 Definitions of Governance
3.1.1 Corporate Governance
The term used in the NHS to mean the system by which an organisation is directed and controlled, at its most senior levels, to achieve its objectives and meet the necessary standards of accountability, probity and openness. Corporate governance is therefore about achieving objectives, including value for money and upholding public service values. The Board have also adopted the principles set out in The NHS Foundation Trust Code of Governance.
3.1.2 Clinical Governance
A Framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. (Scally G
and Donaldson LJ. (1998) ‘Clinical Governance is Here to Stay’)
Clinical governance is the mechanism for understanding and learning to develop the fundamental components required to facilitate the delivery of quality care – no blame, questioning, learning culture, excellent leadership, and an ethos where staff are valued and supported to deliver high quality care to patients.
3.2 The Role of the Board
adopt a systematic process of patient, staff and public involvement, including hearing staff and patient stories at all levels in the organisation.
Further to this:
• The Integrated Governance Framework will ensure the Board and its subsidiary committees are structured effectively and properly constituted.
• Through the implementation of Quality Governance, the Board will ensure it promotes a culture where patients are first, staff learn from experience, and the Trust engages with patients and the public to develop services in the future. • Board business cycles will be clearly set out with actions implemented. • The Board will be responsive to new legislation and NHS policy.
• The Board will ensure Codes of Conduct are upheld and the public service values of accountability, probity and openness in the conduct of business are maintained.
• Board members will receive appropriate induction and ongoing training to ensure their optimal performance.
3.3 Standing Orders and Standing Financial Instructions
• The Trust Standing Orders and Standing Financial Instructions, in accordance with the latest model published by the Department of Health, will provide the regulatory framework for the business conduct of the Trust.
• The Annual Governance Statement (AGS) will be produced on an annual basis, supported by the Assurance Framework and underpinning Trust Risk Management arrangements.
• The content of the AGS is informed by the annual Head of Internal Audit Opinion on the efficacy of the Trust’s internal control mechanisms.
• The AGS is subject to external scrutiny by the Trust’s external auditors on an annual basis.
• Significant weaknesses in the Trust’s internal control mechanisms will be explicitly highlighted in the AGS, together with the actions necessary to address the issues reported on.
3.4 Risk Management Strategy & Board Assurance Framework
• The Risk Management Strategy establishes a consistent and integrated approach to the management of all risk across the organisation.
o provide the framework for achieving robust integrated governance through the control and management of risk to achieve the Trust’s strategic aims and objectives;
o comply with the Care Quality Commission’s regulatory framework and the NHS Litigation Authority Risk Management standards;
o provide assurance that the Trust has an appropriate Board Assurance Framework in place and adheres to guidance on the Statement on Internal Control.
• The Board Assurance Framework provides RCHT with a simple but comprehensive method for the effective and focused management of the principal risks to meeting its corporate objectives. It sets out the controls to mitigate the risk, the sources of assurance which can be provided to the Board to validate their effectiveness and action plans to further reduce the risk or manage it to an acceptable level.
• The Assurance Framework will be a dynamic Board assurance tool, underpinned by the Risk Management programme and the risk register.
• The Trust’s internal business planning and performance monitoring process is linked to the Trust’s principal objectives. This ensures a holistic approach to Board assurance, risk management and performance management frameworks throughout the organisation.
3.5 Demonstrating Quality
The Integrated Governance Framework will ensure the Trust can provide quality evidence through its governance and assurance framework to demonstrate its compliance with the necessary quality and safety standards relevant to an NHS provider organisation. This will include: CQC Registration Regulations (Health Act 2008) – maintaining unconditional registration; Quality Accounts national framework; NHS Litigation Authority (NHSLA) Risk Management standards; CNST Maternity standards: Information Governance Toolkit; Monitor Compliance Framework (Quality), and Trust Commissioners’ Performance Monitoring framework.
The Board will adopt the guidance provided in the National Quality Board report
Quality Governance in the NHS – a guide for Provider Boards, and in particular will
promote the development of team and service based quality goals and measures, to support a Quality focussed culture.
3.6 Financial Governance
The Board will be responsible for the Assurance framework, but the Audit Committee will undertake scrutiny and review of the evidence, in order for the Board to have full confidence.
The Assurance Framework is reported to the Trust Board on a quarterly basis and a detailed review of the Assurance Framework is regularly undertaken by the Audit Committee.
3.7 Information Governance
• The Integrated Governance Framework will ensure all knowledge documents, for example: policies; procedures and guidelines, meet the corporate standards set out in the Trust Policy on Policies. They will be published and archived in accordance with public record requirements using the Trust’s document library. • The Trust will have appropriate information security systems to protect itself, its
partner organisations and its patients.
• Internal information systems will allow appropriate information flow from ‘board to ward’ and ‘ward to board’.
• The RCHT applies information governance standards in accordance with the Information Governance toolkit, ensuring confidentiality, security of personal information, appropriate access to records, legitimate sharing of information, compliance with the Freedom of Information Act and Data Protection Act.
4. ROLE OF THE TRUST BOARD AND ITS SUB-COMMITTEES
Current Trust Governance Structure
Chairman Board of Directors
Chief Executive Audit Committee
Charitable Funds Committee Governance Committee
Trust Management Committee
Finance & Performance Committee Remuneration Committee Clinical Cabinet Chairman Council of Governors Board of Directors Nominations Committee Chief Executive Audit Committee
Charitable Funds Committee Governance Committee
Trust Management Committee
Finance & Performance Committee Remuneration Committee
Proposed Foundation Trust Governance Structure
Table 1.0 – Trust Board Core Sub Committees
Sub Committee Membership Frequency Principal Functions
Audit Committee 3 x Non Executive
Directors
Quarterly To oversee the governance and management of risk and internal control including the provision of the following:
Internal audit
External audit
Other assurance functions
Management Financial reporting Counter Fraud Charitable Funds Committee 2 x Non Executive Directors Director of Finance Director of HR & OD
Quarterly To oversee the management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission and to ensure compliance with the laws governing charitable funds.
Governance Committee 3 x Non Executive Directors Chairman Medical Director Nurse Executive Chief Operating Officer Director of HR & OD
Bi-monthly To review all aspects of the Trust's quality and clinical governance.
Ensuring that the Trust meets all its duties and obligations under the NHS Constitution; plus all other statutory, regulatory, and best practice requirements.
To review all aspects of the risk management process regarding clinical, quality, and safety; and obtaining assurance on all aspects of the Trust's declarations and its registration by the Care Quality Commission.
Finance, Performance & Investment Committee 2 x Non Executive Directors Chairman Chief Executive Director of Finance Chief Operating Officer
Monthly To scrutinise high level operational matters and finance related matters, providing assurance regarding reported results and compliance with Monitor requirements and in particular:
Financial policy, management and reporting
Investment policy, management and reporting Performance Service Improvement. Remuneration Committee Chairman All Non Executive Directors
Quarterly and as required
Delegated powers to determine arrangements on matters relating to remuneration and terms and conditions for Board level post holders. The Committee does not have any powers in respect of the remuneration of Non Executive Directors
It will determine for all staff, under delegated powers, arrangements for any non-contractual payment, in line with Department and SHA guidance. Foundation Trust Project Board (temporary forum) Board Members FT Project Director Monthly during FT application phase
Leadership of the FT Application and Process IBP LTFM Quality Governance Membership Constitution Engagement
Lead for Board Objective Chief Executive Accountable Officer
Executive governance arrangements and significant risk register Delivery of strategic and corporate objectives
Board sponsor for Foundation Trust project Chief Operating Officer Service delivery; transformation and improvement
Performance management of divisions Emergency planning and business continuity Security lead
Patient Facilities and Estates Health and Safety
Records Management
Medical Director Professional leadership – medical
Clinical strategy and the site development plan Caldicott Guardian
Mortality review
Clinical audit and effectiveness GP relationships
Medical-legal matters
Nurse Executive Professional lead – nursing, midwifery, professions allied to healthcare
Clinical governance (quality and safety) Serious incidents (SI)
CQC registration and compliance
Risk management strategy and systems (including health and safety)
Infection, prevention and control Safeguarding adults and children Complaints and PALs
Equality and diversity (patient and public) Patient experience/involvement
Volunteers and spiritual and pastoral care Productive ward and Q&PSIP
Director of Finance & Performance
Financial planning and performance Financial management and accounting Audit and counter fraud
Performance management and reporting Information services and information technology Capital planning
Director of Human Resources and Organisational Development Human resources Organisational development Communications Employment law
Equality and diversity (staff) Staff involvement
Mandatory training Training and development Payroll
Company Secretary Corporate governance
Corporate services Director of Strategy and
Business Development
Foundation Trust application Strategy planning
Communications, engagement and marketing Strategic programme management
Business and customer centred culture Business development
Risk management
4.1 Audit Committee
To independently and objectively monitor and review, on behalf of the Board, the Trust’s processes of risk management, assurance and internal control and, where appropriate, to require the Executive to instigate actions necessary to redress any inadequacies or gaps.
To fulfil its governance and accounting responsibilities by consideration of the integrity, completeness and clarity of annual accounts and the risks and controls around its management.
The Committee shall adopt a risk based approach, but this does not, however, preclude the Committee from investigating, any specific matter relevant to their purpose
4.2 Governance
The Governance Committee is the overarching sub-committee of the Trust Board with responsibility for risk management, clinical governance, information governance, quality assurance and learning from experience.
The Governance Committee is a multi-disciplinary committee whose remit is to drive the quality agenda across the three streams of safety, clinical effectiveness and good patient experience. The Governance Committee oversees the production of the Quality Account and agrees priorities for the forthcoming year and monitoring of the previous year.
The Committee provides assurance to the Board, with the supporting processes are embedded in Divisions and the Trust wide groups promote learning, best practice and compliance with all relevant statutory duties.
4.3 Trust Management Committee (Governance) - TMC(G)
4.4 Clinical Cabinet
The clinical cabinet brings together a leading coalition of consultants and other professionals to advise and assist the Trust Management Committee and the Trust Board in developing a clinical vision and strategic direction.
4.5 Charitable Funds Committee
The Charitable Funds Committee has been formally constituted by the Board in accordance with its standing orders, with delegated responsibility to make and monitor arrangements for the control and management of the Trust’s charitable funds and will report through to the Trust Board. The purpose of this sub committee is to oversee the management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission and to ensure compliance with the laws governing charitable funds.
4.6 Remuneration Committee
The Remuneration Committee is a formal sub-committee of the Trust Board with delegated powers to determine arrangements on matters relating to remuneration and terms and conditions for Board level post holders. The Remuneration Committee will determine for all staff, under delegated powers, arrangements for any non-contractual payment, in line with Department and SHA guidance.
4.7 Finance and Performance Committee
5
OTHER PRINCIPAL COMMITTEES AND GROUPS
5.1 Integrated Performance Management Framework
The following describes the Trust’s Integrated Performance Management Framework.
Committee Membership Reporting Documents
Level 1: RCHT Trust Board
Trust Board Full Board
Integrated Performance Report (IPR)
Board sub-Committee supporting information (e.g. re compliance from Governance Committee or Board assurance from Audit Committee)
Periodic deep dives, seminars or further investigation of issues
Finance & Performance Committee
Non-Executive Directors with CEO & lead executives
Presentation on key performance information, including detailed information and actions on any key business targets currently being failed
Scrutiny and assurance regarding risks and adequacy of actions Escalation actions from Divisional Performance Reviews (by exception) Trust Management Committee Divisional Management Teams with CEO and lead Executives
Scrutiny and assurance regarding risks and adequacy of actions Sign off of Integrated Performance Report
Weekly scrutiny of ‘Hot Report’ of key performance issues suitable for weekly measurement and analysis
Level 2: Divisional Management Divisional Performance Reviews Lead Executives, Divisional Management Team DFM HR Business Partner
Detailed Performance Assurance Framework for Division Divisional commentary
Other issues by exception
Level 3: Specialty / Service Line Specialty and department review process Divisional Director, Divisional Management Team, Specialty Director, Service Lead and Matron
Developing specialty-level PAF (incorporating specialty governance framework)
Individual dashboards, locally held performance information, PLICS data
Risk assessment and mitigation
Level 4: Team / Individual Ward and clinical area reviews Specialty Director, HR and Finance Managers, Matron and Service Lead with Ward Sister or equivalent
Ward trigger tools, budget review and other specific governance indicators as combined in Ward PAF
Risk assessment and mitigation Individual
performance management arrangements
Individual and line manager
Agreed objectives
5.2 Risk Management Committee
The purpose of the Risk Management Committee is to direct the Trust’s response to the management of all areas of risk and to ensure that all elements of the Risk Management Strategy are addressed within available resources. This includes the management of risk in relation to the achievement of the Trust’s corporate objectives and the Assurance Framework.
The Trust is committed to the provision of safe and effective healthcare within an environment which promotes the well being and satisfaction of patients, staff and the public. The Trust will strive to promote and achieve excellence whilst seeking to identify and manage clinical and non-clinical risk.
It is accepted that given the nature of the service provided by the NHS, some risks may never be totally eliminated. It is however essential that NHS trusts have good risk management systems and practices which eliminate risk wherever possible and reduce the impact of those risks that cannot be eliminated to an acceptable level.
5.3 Governance Work Stream groups
Three work stream groups report to TMC Governance and the Governance Committee.
These areas include supporting groups and reports as detailed below: Governance:
• Serious Incident Performance Monitoring • Hospital Infection, Prevention & Control • Quality and Safety Report
• Risk Committee • Quality Accounts
• National Quality Dashboard • Fire, Health and Safety • Claims and Inquests Report Quality Improvement Strategy:
• Nursing and Midwifery Strategy Update • Board Memorandum on Quality Governance • Our People Strategy
Compliance Reporting
• CQC Outcome Assessments
Note 1: Health and Safety Committee
The Royal Cornwall Hospitals NHS Trust is committed to complying with, or exceeding, all statutory requirements of health and safety legislation. This commitment includes fostering a culture which promotes co-operation between management and staff in instigating, developing and carrying out measures to ensure the health and safety at work of all who work in or use the Trust’s services and facilities.
The Trust’s Health & Safety Group will provide the formal forum for consultation with employees as required under the Health and Safety at Work Act 1974, Safety Representatives and Safety Committee Regulations 1977 and by the Health and Safety (Consultation with Employees) Regulations 1996.
Note 2: Information Governance Committee
The Trust has an Information Governance Strategy that defines how the organisation will comply with the principles of openness, legal compliance, information security and quality assurance when managing personal or sensitive information. It covers the Trust’s specific information governance duties that include: Caldicott Guardian; Data Protection; Data Security; Records Management and Data Quality.
In acknowledging the interdependencies between these initiatives, the Trust has in place an Information Governance Committee. The Committee is responsible for assuring delivery of the Information Governance programme set by the Trust Board. Its role is to act as an active management forum that provides direction and visible support for initiatives relating to confidentiality, data protection and security. The Committee reports to the Trust Board via the Governance Committee.
5.4 Divisional Quality & Learning Group
The Divisional Quality & Learning Group is responsible for promoting learning, best practice and a quality culture in the Divisions. The Group works with the Governance Committee and the Audit Committee to assure the Trust Board that robust arrangements are in place for effective clinical governance from ward level upwards.
The group provides a forum for sharing best practice ideas and initiatives thereby ensuring learning from experience takes place across the organisation as a whole.
6. ARRANGEMENTS FOR PARTNERSHIP WORKING
preferred provider for local people needing to access acute and specialist health care. The Trust has plans in place to build on this position over time to broaden the range of innovative community-based health services it offers.
The Trust sets out below the work underway to increase the influence people have on planning and delivery of services.
6.1 Our community and our partners
RCHT engages with its staff, patients, stakeholders and the wider community in helping shape healthcare services for the future. It has made a public commitment to:
• Balance meeting the demands of delivering safe, modern services with that of being responsive to the needs of patients.
• Work together to develop innovative solutions to provide high quality care to our geographically dispersed population; this includes joint responsibility for the NHS Cornwall QIPP programme.
• Strengthen our relationships with the Health and Adults Overview and Scrutiny Committees of Cornwall Council and the Isles of Scilly Council, where we continue to discuss proposals for service development.
• Forge closer links and better understanding with patient support groups, as well as harder to reach and less often heard minority groups within our community, working in partnership with Healthwatch.
• Continue to value the important role our Leagues of Friends have to play in everyday life at our hospitals and their contribution to our future.
The Trust’s model for engagement that was used to inform the Trust’s strategic plan will be further developed to ensure continued involvement as the plan evolves and is refreshed each year. As the Trust makes progress towards its application for Foundation Trust status, it will set up a Membership Scheme, inviting more of the local community to take an active interest in the work and management of the Trust and to become involved in future service development.
7. DIVISIONAL GOVERNANCE ARRANGEMENTS
The Trust manages the delivery of its services through a divisional structure with each division accountable for its contribution to the Trust’s strategic objectives and integrated business plan. Power to act is set out in the Trust’s Scheme of delegation as appropriate to each individual post or generic staff group.
7.1 Divisional Management Teams
Each division is led and managed by a Divisional Management Team, made up of a Divisional Director, Divisional General Manager and Divisional Nurse (or equivalent). This structure is supported by Divisional Governance Leads, Specialty Directors and the corporate functions.
The triumvirate of officers who make up each Divisional Management Team are responsible for providing visionary leadership within the clinical divisions. They ensure the Trust delivers high quality and safe care to patients, which represents best value that includes working closely with partner organisations to deliver innovative models of care.
Divisional Management Teams, together with Specialty Directors, Divisional, and Specialty Governance Leads, have specific roles and responsibilities to ensure that the care and treatment provided to patients meets with the Care Quality Commission’s Essential Standards and Outcomes. Achieving and retaining compliance with these standards is essential to the Trust maintaining its licence to operate as an NHS registered provider, and avoid any legal enforcement action by the Care Quality Commission. Any formal intervention by the Care Quality Commission as a response to concerns over the quality and safety of patient services has a potential impact on the Trust’s Foundation Trust status. The Foundation Trust financial regulator, Monitor, relies on the Care Quality Commission to carry out the quality monitoring role on its behalf.
The detail of these roles and responsibilities is set out in the Trust’s corporate procedure: Registration with the Care Quality Commission Meeting the Essential
Standards and Outcomes of Quality and Safety (June 2010).
7.2 Divisional governance
Each Division will have governance arrangements appropriate to their services and approved by EMG. In principle, this will include a Management Group, through which all aspects of the Business (Quality and Safety, Performance, Finance, Workforce) will be governed.
In order to ensure best practice is promoted and the Quality of Service delivery and learning remains the priority, each Division will also ensure that a Quality forum is in place linking into the Governance Committee and Trust Divisional Quality Group. The details of each of these are provided below.
7.3 Quality Assurance in Divisions
• Development of team/Specialty Quality goals, measures
• Areas designated for improvement as set out in the Trust’s Annual Quality Account
• Achievement of indicators defined in the annual CQUINs payment framework. • Morbidity and mortality reports
• Incident reports and trends • Serious and Critical incidents
• Risk register items which reflect safety and quality
• Compliance with and implementation of national guidelines and standards, including the Care Quality Commission essential standards and outcomes and NICE guidance, quality standards and pathways, together with any other statutory framework or set of standards relevant to the services provided by the division
• Clinical audits • CAS alerts
• Complaints, Claims and concerns • Infection, Prevention and Control issues • Patient Experience
• Confidence in Caring Matrices
• To include the monitoring of progress against associated action plans.
• Monitor progress with current Quality Initiatives. For example: the Quality & Patient Safety Improvement Programme (QPSIP); Productive Ward and Productive Theatres.
• Provide a forum for Continuous Professional Development.
• The Senior Divisional team will ensure that the Specialties have relevant supporting/ parallel working arrangements.
8. INTEGRATED GOVERNANCE SUPPORT
• Managing administration of the Trust’s Registration with the Care Quality Commission (CQC).
• Compliance with the CQC’s minimum standards and outcomes framework. • Compliance with the NHSLA Risk Management standards
• Collecting and storing evidence to support external assessments and preparing submissions to the CQC and NHSLA.
• Supporting CQC Special and Periodic reviews
• Monitoring compliance with NICE guidelines and standard, alerts and other national frameworks.
• Producing the Trust’s annual Quality Account
• Quality & Patient Safety Improvement Programme (QPSIP) • Practice development associated with Patient Safety.
• CQUINs and clinical audit element of the annual contract.
• Risk management, including operational and corporate risk registers. • Serious, critical and other Incident investigation and reporting.
• Aggregating learning from Incidents, Complaints, PALs, Claims, Mortality Review, Inquests and Rule 43 letters.
• Health and Safety advice and support • Complaints and PALs
• Clinical audit programme • Mortality review processes • Patient Experience
• Equality and Diversity
• Administering the Mental Health Act process • Administering the CAS process
The HR function will assist Divisions and co-ordinate Trust wide matters in relation to HR Governance, eg welfare, policies, change management.
9. MONITORING AND REPORTING PROCESS
Trust Board monitors the delivery of this framework primarily through the work of the Governance Committee, supplemented by reports brought directly to Trust Board.
The Governance Committee receives annual reports and regular monitoring information as set out in the workstream structures. This covers all principal strands of governance as part of the Trust-wide assurance framework.
10. Equality and Diversity
This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.
10.1 Equality Impact Assessment
APPENDIX 2. GOVERNANCE INFORMATION
Document Title Integrated Governance Framework
Date Issued/Approved: 18 Jul 14
Date Valid From: 18 Jul 14
Date Valid To: 18 Jul 17
Directorate / Department responsible (author/owner):
Richard Johnson, Head of Quality, Safety and Compliance
Contact details: 01872 252279
Brief summary of contents
This framework describes the system of integrated governance operated within the Trust. It is
designed to ensure the delivery of high quality patient focussed care from an organisation that is well managed, cost effective and has a well-trained and motivated work force.
Suggested Keywords: Governance, Quality.
Target Audience RCHT PCH CFT KCCG
Executive Director responsible
for Policy: Nurse Executive Date revised: 18 Jul 14
This document replaces (exact
title of previous version): Trust Integrated Governance and Quality Strategy Approval route (names of
committees)/consultation: TMC-G Divisional Manager confirming
approval processes Head of Quality, Safety and Compliance Name and Post Title of additional
signatories Not Required Signature of Executive Director
giving approval {Original Copy Signed} Publication Location (refer to
Policy on Policies – Approvals and Ratification):
Internet & Intranet Intranet Only
Document Library Folder/Sub
Folder Clinical / Quality and Safety Links to key external standards None
Training Need Identified? No
Version Control Table Date Version
No Summary of Changes
Changes Made by
(Name and Job Title)
23 Jul 14 V1.0 Initial Issue
Richard Johnson, Head of Quality, Safety and Compliance
All or part of this document can be released under the Freedom of Information Act 2000
This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the
APPENDIX 3. INITIAL EQUALITY IMPACT ASSESSMENT FORM
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age
Sex (male, female, trans-gender / trans-gender reassignment)
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description):
Directorate and service area: Is this a new or existing Policy? New
Name of individual completing assessment: Richard Johnson
Telephone: 01872 252279 1. Policy Aim*
Who is the strategy / policy / proposal / service function aimed at?
This framework describes the system of integrated governance
operated within the Trust. It is designed to ensure the delivery of high quality patient focussed care from an organisation that is well
managed, cost effective and has a well-trained and motivated work force.
2. Policy Objectives* To support achievement of Trust objectives. 3. Policy – intended
Outcomes*
Improved governance leading to safer patient care.
4. *How will you measure the outcome?
See para 9.
5. Who is intended to benefit from the policy?
All patients.
6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy?
b) If yes, have these *groups been
consulted?
C). Please list any groups who have been consulted about this procedure.
No
7. The Impact
Race / Ethnic communities /groups Disability -
Learning disability, physical disability, sensory impairment and mental health problems
Religion / other beliefs
Marriage and civil partnership
Pregnancy and maternity
Sexual Orientation,
Bisexual, Gay, heterosexual, Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been highlighted:
• You have ticked “Yes” in any column above and
• No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or
• Major service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No
9. If you are not recommending a Full Impact assessment please explain why.
Signature of policy developer / lead manager / director Date of completion and submission
Names and signatures of members carrying out the Screening Assessment
1. 2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site. Signed _______________
