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New Good Governance Handbook and QI/Clinical Audit Guide for Provider Boards Kate Godfrey, Director of Operations for Quality Improvement and Development,

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Presentation on theme: "New Good Governance Handbook and QI/Clinical Audit Guide for Provider Boards Kate Godfrey, Director of Operations for Quality Improvement and Development,"— Presentation transcript:

1 New Good Governance Handbook and QI/Clinical Audit Guide for Provider Boards Kate Godfrey, Director of Operations for Quality Improvement and Development, HQIP Dr John Bullivant, GGI Chairman

2 The original Good Governance Handbook (2012) and Clinical Audit Board Guide (2010)

3 Rationale for the new guides changes in the architecture of the NHS in England, Health and Social Care Bill lessons from Mid Staffordshire and Keogh Reviews enhanced focus on well-led organisations Emphasis on board’s role in quality improvement, cost effective outcomes, transparency The target audience for these guides are aspiring lead clinicians and NEDs Also useful to Commissioners

4 Clinical Audit Guide: key themes 1.Suitability of clinical audit: right tool? 2.CA strategy aligned to broader strategic interests 3.Balancing local and national priorities 4.Timescales, prioritisation 5.Professionalism 6.Patient and stakeholder involvement 7.Internal/external relationships 8.Digitalisation & info sharing 9.Education & training

5 Clinical Audit Q&A for Boards QuestionAnswer 1Answer 2 Is our Clinical Audit Strategy aligned to the organisation’s strategic objectives and board assurance framework Clinical Audit is planned and monitored by the clinical audit department and activity is reported on at the relevant board sub- committee Clinical Audits that coincide with strategic priorities are used for assurance We ensure that the clinical audit programme is aligned to our strategic objectives and we have identified where clinical audit can provide assurance and where there are gaps. These gaps will be addressed in forthcoming plans and budgets

6 Clinical Audit Q&A for Boards QuestionAnswer 1Answer 2 Are patients and stakeholders engaged in the clinical audit process? The results of our clinical audits are publicly available and we disseminate a summary of them to commissioners and stakeholders. To ensure PPE, we invite patient and stakeholder representatives and Healthwatch to our quality improvement team meetings. Our clinical audit reports have become more patient-friendly and a summary of the result is disseminated to stakeholders and patients in our newsletter.

7 Group Work Good Governance Institute (GGI) and Healthcare Quality Improvement Partnership (HQIP) Clinical Audit Maturity Matrix Conference copy November 2014 Progress level → Key Elements ↓ 1 Basic Level Principle accepted and commitment to action 2 Early Progress in development 3 Results being achieved 4 Maturity - Comprehensive assurance in place Timescales Our annual audit cycle develops direct year-by- year clinical audit data. We have reviewed how we can use audit data more intelligently to design measures to improve outcomes, especially in areas where standards have not been met. We analyse clinical audit data systematically and conduct re- audits in areas where standards have not been met to ensure improvements to the quality of our services. We operate a rolling audit programme, which covers all stages on an on-going basis, and ensures prioritisation beyond the annual cycle. Education and training We run regular sessions to train new Clinical Audit staff and junior doctors in clinical audit methodology. We recognise the importance of training opportunities for all members of staff involved in the clinical audit cycle to understand statutory guidance and how to use clinical audit most effectively. Clinical audit is covered in our inductions and further learning material is provided by the organisation. Junior doctor clinical audit projects are supported by the clinical audit team. Broadening our education and training approach to quality improvement and clinical audit in particular is already showing greater staff engagement in planning, conducting and evaluating national and local clinical audit. Junior doctor clinical audit and other quality improvement projects are supported by the clinical audit team and their suggestions for improvements are welcomed. Clinical audit is an important feature of our induction and further training programmes on clinical governance. In addition, we have regular clinical audit workshops and invite our staff to participate in further speciality specific external training and networking. Junior doctor clinical audit quality improvement projects are a valuable quality improvement resource, and focus on priority issues.

8 The Good Governance Handbook: key themes 1.Clarity of purpose, roles and behaviours 2.Application of Principles 3.Leadership & strategic direction 4.Effective relationships – external stakeholders, patients and community 5.Effective relationships - Internal incl. members

9 The Good Governance Handbook: key themes 6.Transparency & public reporting 7.Systems and structures: Quality and safety, boundary issues 8.Challenge on delivery of agreed outcomes 9.Risk & Compliance 10.Organisational effectiveness: adding value

10 Good Governance Q&A for Boards Example assurance question Answer 1Answer 2 Do we ensure clarity about the purpose, roles and desired behaviours of our board? The purpose and role of our board is adequately described by the regulator, and in our contracts. We have used the various templates available to organise how our board operates at this level. Our governance procedures and activities are focused on outcomes and the quality of care we provide. Good governance is of concern to everyone in our team, with the board providing strong support at all levels and assurance as well as ensuring constant improvement.

11 Good Governance Q&A for Divisions/Directorates Example assurance question Answer 1Answer 2 Does our division/ directorate apply each of the principles of good governance in its day-to-day workings? Our division/directorate management focuses on supporting the board and implementing its decisions. Our division/directorate management applies the principles of good governance. It ensures the implementation of the board’s decisions but also scrutinises and challenges the latter. Adhering to the subsidiarity principle, we delegate decisions to the wards in our directorate/division where appropriate.

12 Good Governance Q&A for Departments Example assurance question Answer 1Answer 2 Does our department have effective external relationships with stakeholders, patients and the community? The organisation has a PALS and PPIteam who undertake this. Our well-established procedures ensure close collaboration with commissioners, patients, carers and third party organisations when a patient is discharged into the community. The department engages regularly with patients, formal and informal carers and other community organisations to ensure continuity in our patients’ care.

13 Barriers to change: lessons learnt Current practice in escalating Clinical Audit into decision-making and actions Board assurance – strategic use and relationship with internal audit The role of key stakeholders in Clinical Audit and quality improvement and what guidance is needed What is needed to guide assurance for commissioners? The current challenges and opportunities around information governance and partnership working in Clinical Audit (including cross- boundary use in health and social care) Who uses this guide? How might the guide be useful in induction and training?

14 Next steps – project timeline Publication December 2014 / January 2015 2015 workshops: Wednesday 14 January – LONDON Wednesday 21 January – MANCHESTER Thursday 22 January – LEEDS Wednesday 28 January- BIRMINGHAM Thursday 29 January- BRISTOL Wednesday 11 February – LONDON More info at or

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