Monitor has issued its latest guidance “Quality Governance: How does a board know that its organisation is working effectively to improve patient care?” The Guidance is addressed to boards of NHS provider organisations. However, as the Guidance itself points out (para.9) it has application across a range of functions including senior management, internal and clinical audit, and clinical and nursing services.
The Guidance will also be of assistance to independent sector providers, in reviewing their own quality governance systems, not least because it is likely to inform how services are regulated and inspected in relation to their governance functions.
The issue of quality governance is extremely topical in the wake of the Mid Staffs Inquiry Report, and Monitor’s Guidance is an extremely useful document in implementing some of the themes of the Inquiry report in terms of steps that provider organisations should take to properly put quality at the heart of their services.
It is essential to ensure that boards are properly assured (on the basis of a range of reliable information) in relation to quality issues rather than solely relying upon reassurance provided by the executive directors or members of staff.
The Guidance includes a useful summary, at para.114, of approaches which boards can follow to ensure they have effective systems and processes in place to understand current and future risks to quality as follows:
- maintaining oversight of risks to compliance with essential standards, such as CQC standards;
- reviewing the risk estimates contained in CQC Quality and Risk Profiles and following up underlying issues;
- reviewing ongoing performance in national clinical audits, clinical registries, clinical services accreditation schemes and related national quality improvement initiatives. These provide data that permits comparison with other providers;
- setting minimum common standards and assuring the board that these are not being compromised;
- reviewing patient safety incidents from within the trust and wider NHS and ‘near misses’ to identify similarities or areas for organisation-wide learning;
- receiving assurance on headcount implications of CIPs through review of, for example, the National Workforce Assurance Tool; and
- reviewing the learning from complaints, claims and Rule 43 coroner reports.
Where the Guidance is particularly useful, however, is in providing some “flesh on the bones” of the issues that provider organisations need to consider as part of the Quality Governance Framework. The Guidance provides more detailed questions which boards should ask themselves, discusses the principles that support effective assurance and escalation, and, helpfully, sets out a number of examples of how different provider organisations have approached these challenges. A review of the principles and examples is extremely informative for all boards of provider organisations. We would encourage all boards to review the guidance for full details of some of the principles and examples of good practice set out.
Application to foundation trusts (FTs) and aspirant trusts
The Guidance is directly relevant to FTs and aspirant trusts as it assists boards in answering the 10 questions posed in the Quality Governance Framework (relating to Strategy for Quality; Capabilities and Culture; Processes and Structures; and Measurement of Quality). Aspirant trusts need to ensure they have a Quality Governance Framework score of less than 4 as part of the authorisation process.
For existing FTs, ongoing compliance with the Quality Governance Framework is perhaps of even greater significance. The Guidance provides essential information for FTs to consider in ensuring their compliance with Condition FT4 (NHS Foundation Trust governance arrangements) of their provider licence. Paragraph 6 of Condition FT4 requires FTs to have systems and/or processes which ensure:
“(a) that there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;
(b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations;
(c) the collection of accurate, comprehensive, timely and up to date information on quality of care;
(d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;
(e) that the Licensee including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and
(f) that there is clear accountability for quality of care throughout the Licensee’s organisation including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate”.
The Guidance will therefore be essential for FTs to take into account in designing their systems and processes. Furthermore, the extent to which FTs comply with the Guidance will provide important evidence for the retrospective and prospective corporate governance statements which they are required to submit under paragraph 8 of Condition FT4. It is important that FTs have appropriate evidence to support corporate governance statements not only for internal assurance, but also to enable them to meet any enquiries raised by auditors or Monitor itself using its power to require documents and information under section 104 of the Health & Social Care Act 2012.
The Guidance sets out four main themes which provider organisations need to address in relation to quality governance:
- Engagement on quality;
- Gaining insight and foresight into quality;
- Accountability for quality; and
- Managing risks to quality.
Engagement on quality
- Culture – the effectiveness of unannounced quality-focused visit to wards by board members.
- Clinical leadership – securing clinical input on the “bedside impact” of proposed changes.
- Communication – sharing the data and information that a board receives on quality with relevant staff as early as possible.
- The importance of regular ‘local’ staff surveys or ‘temperature checks’ in aiding an understanding of the ongoing effects of board decisions on staff morale. The Guidance states that “some trusts have included specific areas that must be addressed in conversations between boards and staff when they meet, for example: early warning indicators of the impact of cost improvement programmes; staff suggestions to improve service quality; priorities for next year’s Quality Account; and their top three safety concerns”.
- Quality Accounts – “many trusts have introduced a monthly quality report to the board that mirrors the content of the Quality Account” which “improves the assurance that the board receives at the end of the year when the Quality Account is signed off”.
- Integrating commissioners’ experience as a crucial dimension of quality – the Guidance points out that CCGs will have their own intelligence of providers’ services based on contract monitoring and patient and public engagement and that trusts therefore “need to ensure that they have considered the views of commissioners in setting and monitoring quality goals”.
Gaining insight and foresight into quality
- Measurement, reporting and monitoring - boards should agree a set of quality metrics which, alongside national, regional and local metrics, should be matters which are relevant in the context within which the organisation and its partners are operating.
- Data quality – the Guidance makes the point that effective performance management relies on provider organisations’ ability to have good quality data on their performance. This in turn highlights the need for boards to establish data quality assurance programmes rather than relying on the “limited nature” of, for example, reporting under the Information Governance Toolkit.
- Benchmarking – provider organisations should take appropriate steps to benchmark their performance, both in terms of internal benchmarking across services as well as external benchmarking against properly comparable organisations; the Guidance refers to the importance of peer review in encouraging the sharing of experience, knowledge and expertise.
Accountability for quality
- Assurance and Escalation Framework – the Guidance states that all provider organisations should develop an overarching framework covering:
- processes so that all staff can raise concerns about the impact of Cost Improvement Plans on the quality of care;
- defined and understood processes for exception reporting of incidents to the board;
- identification of data quality concerns; and
- identification of early warning triggers in relation to workforce, finance and clinical services.
- Roles and responsibilities - boards need to ensure that they and their committee structures adequately cover the quality governance agenda whilst minimising potential gaps and duplication.
- Audit functions – the Guidance stresses the importance of “effective use of the internal audit and clinical audit functions to provide an overview of the quality governance assurances through a systematic review of the assurance processes”.
Managing risks to quality
- Local Risk Registers – “in order to ensure that the board has visibility of risks as they emerge, trusts should ensure the efficient development of clinical unit risk registers through local risk escalation”.
- Clinical outcomes versus cost efficiency – the development of CIP schemes “should begin at clinical unit management level” and CIPs which carry a higher risk of impacting on quality “should incorporate explicit plans for a proportionate and systematic post-implementation review”.
There will be much in the Guidance which boards are already doing to ensure appropriate quality governance within their organisations. However, there will inevitably also be more that each organisation can do. We would encourage all boards to closely consider the Guidance to see whether more can be done to embed processes of quality governance throughout their organisations. This is particularly significant for foundation trusts and aspirant trusts given their need to comply with the Quality Governance Framework and the implications of Monitor’s Licence Condition FT4. However, there are also lessons around good governance and engagement with staff and patient groups which may provide useful learning to independent sector providers as well as the NHS.
The development of your board governance, assurance and accountability frameworks need careful consideration. Bevan Brittan brings extensive experience of supporting clients in developing, implementing and ensuring robust governance and decision making processes to deliver our clients’ aims. We pride ourselves on our creative thinking and have a long history of being at the forefront of developing innovative approaches. We also adopt a practical and proactive approach in providing solutions to ensure our clients are always fully up-to-date with the continually evolving requirements around compliance, regulatory, economic, performance and clinical quality dynamics.
As well as providing assistance in the development of appropriate and robust governance arrangements, we can provide training and development programmes for boards and senior managers.
We are accredited suppliers and assessors for Monitor and the DH in relation to the Board Governance and Assurance Framework for aspirant trusts and we have a wealth of experience in these areas which will be of use to providers.
We were also involved as a recognised legal representative throughout the Mid Staffs Inquiry proceedings and are working to assist clients understand how best to embed the learning of the Francis report and the government response in the services they provide.
If you would like to discuss how we can support you in developing your governance, assurance and accountability arrangements please contact us.