Trust Board papers November 2012 - Barking Havering and ...

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