Terms of reference - Patient Safety and Quality Standards Committee (Ps and Qs) - North Tees and Hartlepool NHS Foundation Trust

1. Purpose

The Patient Safety and Quality Standards Committee has been given the delegated authority by the Trust Board to ensure the highest possible standards of clinical practice within the Trust. The Patient Safety and Quality Standards Committee is primarily responsible for advising the Board of Directors on clinical and non-clinical risks relating to the delivery of quality standards; this includes ensuring there is appropriate escalation where risk controls are perceived to be no longer effective. The Patient Safety and Quality Standards Committee will ensure the Trust has in place the systems and the processes to support individuals, teams and corporate accountability for the delivery of safe and effective, patient-centred, high-quality care.

The Patient Safety and Quality Standards Committee will be responsible for a work programme determined on an annual basis in accordance with the strategic objectives of the Trust and in agreement with the Board of Directors.

2. Duties of the Committee

The duties of the Committee are to consider elements of patient safety and quality aligned to the CQC Domains and Key Lines of Enquiry which question:

Are our services safe?
Are our services caring?
Are our services responsive?
Are services effective?
Are services well-led?
Are we using our resources effectively?

More specifically to:

Ensure patient safety and quality risks are identified and are aligned with the Trust’s long term strategic and operational objectives through the development and monitoring of the Board Assurance Framework.
Ensure that controls and assurances specific to patient safety and quality risks describe how the Trust will manage the anticipated risks to achieving strategic objectives.
Understand the trends presenting within clinical risks and seek assurance on the control of these within the Trust.
Initiate corrective action where gaps are identified in relation to controls and actions specific to patient safety and quality risks and monitor improvements.
Utilise intelligence to identify where there are gaps in controls i.e. Care Quality Commission (CQC) Key Lines of Enquiry or Business Intelligence Software
Ensuring action plans are in place and monitored to identified risks.
Ensure understanding of trends in relation to feedback from patients/service users and the initiatives implemented to resolve concerns and identify excellence.
Ensure the Quality Report/Accounts are discharged and that lessons learned and disseminated to all professionals within the Trust
Ensure that the trust continues to fulfil any requirements as determined by the Care Quality Commission and other regulators.
Receive reports and/or minutes from the identified sub-committees and meetings for monitoring and assurance purposes; ensuring action or decisions are made as and when identified.
Prioritise and promote consistent Patient Safety and Clinical Quality using a model of openness and candour.
Promote the sharing of good practice and positive innovative changes implemented within services, actively empowering staff to improve quality.
Agree on the contents of an annual work plan, and monitor its delivery.
Provide reports for Trust Board in a timely manner.

3. Membership

Membership of this committee is focused in order to enhance Board oversight of quality performance and risk by ensuring input from people with particular quality expertise and responsibility for frontline clinical leadership. The Chairman of the Committee is a nominated Non-Executive Director and in his/her one of the other Non–Executive Directors will chair absence the meeting.

The core membership is identified as

Non-Executive Director Representation x 2
Health Care User Representative
Chief Nurse/Director of Nursing, Patient Safety and QualityDeputy Chief Nurse/Director of Nursing, Patient Safety and QualityMedical DirectorDeputy Medical DirectorChief Operating OfficerDirector of FinanceAssociate Director of Nursing Patient Safety, Risk and GovernanceAssistant Director Nursing / Infection Prevention and Control
Head of Patient Safety

The staff below will be invited to the meeting as required.

Senior Allied Health Professional Representative
Care Group Clinical Lead
Head of Nursing
Head of Midwifery
Care Group Director
Care Group Manager
Chair of the Audit and Clinical Effectiveness Committee
Senior Clinical MatronPatient Experience Manager
Patient Safety Specialist
Patient Safety Partner (as identified)

This list in not exclusive and other colleagues will be requested to attend as identified.

4. Quorum

The necessary quorum will be a minimum of 2 Trust Directors, one of which must be a Non-Executive Director, and will also include one Clinician and one Senior Nurse.

Thus, the Committee when quorate shall be competent to exercise all business; without being quorate the committee can consider reports and presentations but decisions cannot be made.

Core representatives of the Committee will be required to attend a minimum 9 out of 12 meetings annually. If specified members cannot attend then they should identify a deputy to attend in their place, attendance will then be recorded. Attendance will be monitored on an annual basis.

5. Meeting frequency

The Committee will meet monthly to ensure delivery of all business.

An extraordinary meeting can be called by minimum of 2 Trust Directors to deal with any urgent patient safety or quality matters.

6. Notice of Meeting

A programme for all meetings will be agreed annually.

Administrative support will be provided by the Nursing Administration team and will include the recording of minutes and maintenance of a record of matters arising and issues to be carried forward.

Agendas and supporting papers will be available 5 work days prior to the meeting.

Any member can request an item to be included on the agenda, which should be made to the Chair at least 10 days prior to a meeting. Any additional agenda items received after this date will be considered at the discretion of the Chair.

7. Reporting responsibilities

The Committee is a statutory sub-committee of the Board and will provide monthly reports to the Trust Board to include summary details of serious incidents and quarterly incident reporting of all other incidents including claims and complaints.

In addition, the Committee will report to the Audit Committee on a formal quarterly basis with recommendations for any appropriate areas where action required. Information will also be provided for inclusion into the Annual Governance Statement and Quality Accounts.

The Committee shall request and review reports and positive assurances from Directors and Managers on the overall arrangements for governance, risk management and internal control.

In addition, the Committee will review the work of other committees within the Trust whose work can provide relevant assurance to the Patient Safety and Quality Standards Committee.

The following groups will provide minutes to the Committee for monitoring and assurance purposes:

Excellence as Our Standard Steering Group
Safety Panel
Incident Review Panel (IRP)
Audit and Clinical Effectiveness (ACE) Committee
Patient Safety Committee
Control of Infection Committee
Drugs and Therapeutics Committee
Health, Safety & Welfare Committee
Critical Care Delivery Group
Organ Donation Committee
Human Tissue Authorisation Committee
Trust Research Advisory Committee (Bi-annual)
Trust Resilience Forum incorporating Civil Contingencies Act
Resuscitation Committee
Radiological Protection committee
Patient Carer and Experience Committee
Safeguarding Committee

The Chairpersons of all of the reporting groups will provide summary reports of all minutes; Chairs of committees/groups/meetings reporting to the committee will ensure there is clear escalation of key information and learning identified to Patient Safety and Quality Standards Committee. Additionally Chairs of meeting that report to Patient Safety and Quality Standards Committee should ensure that key information from the committee is shared with there own meeting. Summaries will identify also identify details of good practice that can be shared and celebrated.

Reporting committees and groups can attend the committee meetings to discuss any issues or concerns identified; if this is at short notice then the Chair through the Associate Director of Nursing Risk and Governance should be informed of the need to consider items in the agenda.

The core group members will ensure key issues and learning from the meeting are shared within their structures to support improvements across the Trust. Issues identified within those structures as appropriate for escalating to Patient Safety and Quality Standards Committee should raise with either the Chair, Chief Nurse/Director of Nursing, Patient Safety and Quality or the Medical Director for discussion and where appropriate schedule inclusion in the meeting.

Regular reports scheduled in the forward plan will highlight key areas of change to the committee for discussion.

8. Other matters

All new members to the Committee will receive induction to facilitate understanding of Committee business by the Associate Director of Nursing Patient Safety, Risk and Governance
The Committee has authority to seek information details from all Care Groups/Directorates / any Trust employees.