Annual Report and Accounts - The Great Western Hospital

Enhanced Quality Governance Reporting
Quality governance is combination of structures and processes at and below Board level to lead on
trust-wide quality performance including:
• ensuring required standards are achieved;
• investigating and taking action on sub-standard performance;
• planning and driving continuous improvement;
• identifying, sharing and ensuring delivery of best-practice; and
• identifying and managing risks to quality of care.
Arrangements in place to ensure quality governance and quality are discussed in more detail within
the annual governance statement (section14 refers) and the quality report (section 6 refers).
3.15 Monitor’s Quality Governance Framework
The Trust has had regard to Monitor's quality governance framework in arriving at its overall
evaluation of the organisation’s performance, internal control and board assurance framework. In
June 2011 and again in September 2011, the Trust undertook an evaluation of its strategy;
capabilities and culture; processes and structure and measurements mapping them against
Monitor’s Quality Governance Framework. In addition, the Trust commissioned an independent
audit which provided substantial assurance regarding the Trust’s quality governance arrangements.
The Trust has not developed one specific action plan to improve the governance of quality.
However, throughout the Trust there are plans or ongoing processes which contribute to its
improvement. Examples of this include: -
• Development of the Trust’s business strategy with particular emphasis on quality.
• Monthly reporting to the Board on risks and potential risks to quality, with action plans in
place to address any gaps in assurance.
• Ongoing Board development with the Institute for Innovation and Improvement and
refreshment of the Board to ensure that the Board has the necessary skills and qualities to
manage the Trust and deliver the quality agenda.
• Promotion of a quality focused culture throughout the Trust evidenced by the roll of staff
values and improved communication and feedback mechanisms. Quality is considered in
developing policies and procedures for the Trust with consideration given to the impact on
clinical effectiveness, patient experience and the quality of care.
• There are clear processes for escalating quality performance issues to the board. These
are documented, with agreed rules determining which issues should be escalated. These
rules cover, amongst other issues, escalation of serious untoward incidents and complaints.
Robust action plans are put in place to address quality performance issues.
• Quality information is analysed and challenged in a number or areas. The board reviews a
monthly ‘dashboard’ of the most important metrics.
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