Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
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CQC Update Report<br />
<strong>2012</strong><br />
ASSESSING &<br />
MONITORING<br />
70. Ensure that it has adequate<br />
systems of governance to<br />
promote high quality care for<br />
patients <strong>and</strong> to deal with<br />
concerns about performance in<br />
an effective <strong>and</strong> timely manner.<br />
Clinical <strong>and</strong> committee structures<br />
have been reviewed <strong>and</strong> a new<br />
Clinical Governance Structure has<br />
recently been considered by the<br />
<strong>Trust</strong>’s <strong>Board</strong>.<br />
Exp<strong>and</strong>ed central data collection<br />
for the Quality <strong>and</strong> Safety<br />
Committee has been proposed. A<br />
central monitoring <strong>and</strong> evidence<br />
database has been introduced for<br />
Serious Incidents, with <strong>Trust</strong>‐wide<br />
audits being introduced <strong>and</strong> KPIs<br />
introduced for reporting <strong>and</strong><br />
completion of investigations. A<br />
web‐based incident reporting<br />
system is being introduced across<br />
the <strong>Trust</strong> after a pilot in maternity.<br />
• All Clinical Directorates have clinical governance<br />
meetings which feed into the Quality <strong>and</strong> Safety<br />
Committee structure.<br />
• Dashboards developed for Quality KPI reports.<br />
• Rolling risk reviews in place for Q&S Committee<br />
• Action Plan monitoring in place.<br />
• Snapshot Audits underway<br />
• Web‐based tracking system in place with on going<br />
training at Induction.<br />
Pam Strange<br />
MET<br />
BUSINESS<br />
AS USUAL<br />
ASSESSING &<br />
MONITORING<br />
72. Carry out a comprehensive<br />
review of all corporate <strong>and</strong><br />
clinical governance systems<br />
across the organisation to<br />
ensure that effective <strong>and</strong><br />
streamlined systems <strong>and</strong><br />
reporting structures are in place<br />
to provide robust assurance to<br />
the board.<br />
Clinical <strong>and</strong> committee structures<br />
have been reviewed <strong>and</strong> a new<br />
Clinical Governance Structure has<br />
recently been considered by the<br />
<strong>Trust</strong>’s <strong>Board</strong>.<br />
A complete review of <strong>Trust</strong><br />
corporate committees has been<br />
completed <strong>and</strong> was recently put to<br />
the <strong>Trust</strong> <strong>Board</strong>. A complete<br />
review of maternity clinical<br />
governance was completed by<br />
October 2011 to ensure full<br />
integration with the <strong>Trust</strong>’s main<br />
governance structures. The review<br />
also led to Divisional managers<br />
taking on responsibility for alerting<br />
clinical governance teams to all<br />
external quality <strong>and</strong> safety<br />
recommendations (reinforced<br />
through stringent audit <strong>and</strong><br />
• New Director of Governance <strong>and</strong> Special Projects in<br />
post (September <strong>2012</strong>)<br />
• CDs Governance meetings supported by Facilitators.<br />
• SI reviews embedded in performance structures<br />
• QIPP programme supported by QIAs (Quality Impact<br />
Assessments) within a formalised governance structure.<br />
Averil<br />
Dongworth<br />
MET<br />
BUSINESS<br />
AS USUAL<br />
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