Composition

Role and purpose

The Quality and Performance Committee has been established as a formal Committee of the Board of Directors. The Quality and Performance Committee (hereinafter referred to as ‘the Committee’) has no executive powers.

The purpose of the Committee is to provide assurance relating to all aspects of quality, safety and operational performance including delivery, governance, clinical risk management, research and development and the regulatory standards of quality and safety, thereby ensuring the best clinical outcomes and experience for patients.

The Chair of the Committee will provide a report to the Board of Directors after each meeting based on the 3A model.

Membership

• Three Non-Executive Directors – one of whom shall be the nominated Chair and one with relevant clinical experience.
• Director of Quality, Innovation, and Improvement
• Medical Director
• Chief Operating Officer/Deputy Chief Executive
• Director of Corporate Affairs

The following officers shall be invited to attend meetings of the Committee in an advisory capacity when agenda items require them to be present. They are not routinely required to attend.

• Chief Consultant Paramedic
• Chief Pharmacist
• Patient Safety Specialist
• Chief of Regulatory Compliance and Improvement
• Consultant Midwife
• DIPC / Assistant Director of Nursing

Quoracy

The required quorum for the transaction of business shall be five, which is to include at least two Non-Executive Directors and at least three Executive Directors, one of which must be either the Director of Quality, Innovation and Improvement or the Medical Director.

Meeting frequency

The Committee will meet bimonthly.

Meeting support

The Committee will be supported administratively by a member of the Corporate Governance Team, who will agree the agenda with the Chair, collate the papers and produce minutes within 48 hours of the meeting.

Remit of the committee

The Commitee will:

Quality:

• Ensure that all statutory elements of clinical governance are adhered to within the Trust.
• Approve the Terms of Reference and membership of its reporting committees (as may be varied from time to time at the discretion of the Committee) and oversee the work of those sub-committees, receiving reports from them as specified by the committee in the sub-committee’s terms of reference for consideration and action as necessary.
• Consider maters referred to the Committee by the Board of Directors or other committees thereof that require urgent attention.
• Consider maters escalated to the committee by its own sub-committees.
• Approve the annual Clinical Audit Programme on behalf of the Board of Directors and ensure it is consistent with the audit needs of the Trust.
• Make recommendations to the Audit Committee concerning the annual programme of internal audit work, to the extent that it applies to maters within these terms of reference.
• Ensure the registration criteria of the Care Quality Commission continue to be met.
• Review Trust compliance with the national standards of quality and safety of the Care Quality Commission, and licence conditions that are relevant to the Committee’s area of responsibility.
• Ensure that the Trust has appropriate processes in place that safeguard children and vulnerable adults.
• Seek assurance through review of the routine Legal and Clinical Governance reports that the Trust incorporates the recommendations from external bodies, (e.g. the Kirkup Maternity Review) as well as those made internally, (e.g. in connection with serious incident reports and adverse incident reports) into practice and has mechanisms to monitor their delivery.
• Ensure that robust arrangements are in place for the review of patient safety incidents (including never events, complaints, claims, PFD reports from HM Coroner) from within the Trust and wider NHS to identify similarities or trends and areas for focused or organisation-wide learning.
• Ensure that actions for improvement identified in incident reports, e.g. reports from HM Coroner, Learning from Deaths and other similar documents are addressed. 
• Idenô€†Ÿfy areas for improvement in respect of incident themes and complaint themes and ensure appropriate action is taken. 
• Ensure implementation of the Patient Safety Incident Response Framework (PSIRF) 
• Ensure that any areas of concern identified from the Commitee’s review of clinical quality and any identified gaps in controls in relation to delivery of relevant Trust strategic objectives are reflected on the Board Assurance Framework. 
• Receive and review the Trust’s annual Quality Report and make recommendations as appropriate for Trust Board approval. 
• Ensure that the Trust has a robust process in place to proposals for cost improvement programmes and other significant service changes and to monitor the impact of proposals for cost improvement programmes and other significant service changes on the Trust’s quality of care (ensuring that there is a clear process for staff to raise associated concerns and for these to be escalated to the Committee) and report any concern relating to an adverse impact on quality to the Trust Board; 
• Ensure that there is an appropriate process in place to monitor and promote compliance across the Trust with clinical standards and guidelines including but not limited to NICE guidance and guidelines. 
• Monitor trends in complaints received by the Trust and commission actions in response to adverse trends where appropriate. 
• Through the Trust’s Annual Quality Report, monitor the development of quality indicators, 
• Ensure that there is an appropriate mechanism in place for action to be taken in response to the results of clinical audit and the recommendations of any relevant external reports (e.g. from the Care Quality Commission). 
• Ensure the Trust is outward-looking and incorporates the recommendations from external bodies into practice with mechanisms to monitor their delivery. 
• Oversee and seek assurance on the systems in place to ensure compliance with statutory and regulatory requirements for infection prevention and control. 
• Receive assurance on the systems in place to ensure compliance with statutory and regulatory requirements for medicines management (Medicines Act (1968) and Controlled Drugs (Supervision of Management and Use) Regulations (2013).
• Oversee and seek assurance on the clinical impacts from transforming the provision of Trust services and ensure that all efficiency programmes have had a quality impact assessment.
  

Performance

• Monitor performance against nationally mandated KPIs and performance measures (e.g. ARP) issued by the regulator (NHSE) and other relevant regulatory bodies.
• Provide detailed scrutiny of the monthly IPR and relevant NHSE returns and seek assurance of the actions in place to deliver against the targets and any mitigation where performance is not on track including but not limited to:
  • Emergency response times
  • Call pick up
  • Long waits
  • Benchmarking 
  • Ambulance Handovers 
  • 111 performance 
  • PTS performance 
• Review the Integrated Quality and Performance report ahead of the Trust Board
• Provide detailed scrutiny of the forward performance plan, including metrics required by the NHSE such as ARP trajectories, demand projections and incident outcomes.
• Review performance against contractual performance targets agreed with commissioners – explicitly monitoring performance for all funded services as well as any subsequent variations or alterations to this plan.
• Review Emergency Preparedness Resilience and Response plan and performance.
• Consider issues referred by other Board Committees relating to Trust level performance issues.
• Consider benchmarking information in relation to operational performance such as model ambulance and the ambulance balanced scorecard.

The Chair of the Committee shall maintain an effective relationship with the Chair of the Audit Committee and Resources Committee and may, from time to time, refer matters to the Audit Committee and/or other Board Committees as appropriate for consideration.

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