Governance in the HPSS

1. Governancein theHPSS The Whole Picture

2. What is “Governance”? • “the system by which an organisation directs and controls its functions and relates to its stakeholders” HM Treasury • In other words, the way in which organisations: • manage their business • determine strategy & objectives • go about achieving these objectives • maintain quality standards • engage with and assure stakeholders

3. What are the drivers for change? • Universal concern about standards of governance • Requirement for wider Statement of Internal Control DAO (DFP) 52001 & DAO (DFP) 25/03 • General duty to protect, including Statutory Duty of Quality

4. Examples of universal concern • Cadbury Report • Combined Code – Turnbull Report • Bristol Royal Infirmary • Harold Shipman • Senior Executives’ Pay • Organ Retention Inquiry • Compensation Payments for Clinical Negligence • Briggs Case (Lewis Review)

5. DAO (DFP) 5/2001 – risk management and the wider Statement on Internal Control Risk Management - The Turnbull report states that a sound system of internal control “depends on a thorough and regular evaluation of the nature and extent of the risks to which the company is exposed”. It further states that the purpose of internal control“is to help manage and control risk rather than to eliminate it”. Statement on Internal Control - The SIC should therefore be the end result of a process of management that is embedded in the planning, operational, monitoring and review activities of the body, these activities being the critical elements of the statement. Production of the SIC should not be conducted as an “add-on” end of year activity.

6. Duty to Protect Across the UK, 10% will suffer harm in the NHS • 30,000 deaths • 25,000 permanent disability Half of these potentially preventable • 400 deaths or serious injuries from medical devices • 10,000 serious adverse reactions to drugs • 1150 suicides amongst people already in contact with social services • 28,000 written complaints about clinical treatment • 15% of infections may be avoidable • £400m in settlements • £1bn hospital acquired infections • £2bn prolonged hospital stays (£200m in delayed discharges alone)

7. The nature of risk • Risk doesn’t recognise internal management boundaries. The systems and controls put in place to manage it must be comprehensive and organisation-wide

8. Finance Organisation Corporate Risk Clinical & Social Care

9. Risk management at the heart of governance and assurance • Reducing risk is not just about financial or management probity. It is also about improving the quality of services and the user experience of those services. A sound system of organisation-wide risk management must, therefore, be at the heart of all the mechanisms we put in place to offer assurance that these things are happening.

10. The risk management process Governance Clinical and Social Care Organisational Financial Objectives Audit and Review Reporting and Assurance Risk Identification Risk Evaluation Controls Organisation-wide Risk Management HPSS duty to protect users, staff and other stakeholders DAO 5/2001 – Statement on Internal Control Universal concern about improved governance

11. Controls assurance standards • Supplement but do not replace the need for an organisation-wide system of risk management • Designed to help HPSS bodies to provide evidence that they are doing their reasonable best to manage themselves so as to meet their objectives and to protect users, staff, the public and other stakeholders against risk of all kinds • Will eventually provide the focus for a common approach to controlling key areas of potential risk and reporting on the effectiveness of those controls across the HPSS

12. Controls assurance standards in place for 2003/04 • Financial Management (Core Standard) • Governance (Core Standard) • Risk Management (Core Standard) • Medicines Management • Human Resources • Medical Equipment and Devices

13. Controls assurance timetable • Initial 6 standards published formally in April 2003 • HPSS bodies expected to make first reports on compliance in May 2004 • Development of further standards continuing during 2003/04 • All standards will be introduced within a managed timetable

14. Best Practice Best Care 2001 • A framework to raise the quality of services and to tackle issues of poor performance • Announced in the NI Executive’s first Programme for Government

15. Why do we need new approach? • Public expectation and growing awareness in the face of scandals • Many services not subject to independent regulation and inspection • Unacceptable variations in the standards of care, treatment and services • The pace of advance in medicine, technology and professional practice • Developments elsewhere in the UK and beyond

16. The HPSS (Quality, Improvement and Regulation) (NI) Order 2003 • Statutory Duty of Quality on a par with statutory duty in relation to financial stewardship • Minimum standards of care • Regulation and registration • HPSS Regulation and Improvement Authority

17. Setting the standard • Links to National Institute for Clinical Excellence (NICE) and Social Care Institute for Excellence • Minimum standards of care • Establishment of HPSS Standards and Guidelines Unit • Service Development Frameworks

18. Monitoring and Regulation • Extension of regulation to wider range of services • Regulations on minimum standards of care • Health and Personal Social Services Regulation and Improvement Authority (HPSSRIA)

19. Clinical and Social Care Governance • A framework through which HPSS bodies are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical and social care will flourish. It is a concept for the organisation as a whole.

20. Organisational characteristics of sound C&SCG • Effective engagement with users, carers and communities in the development, delivery and evaluation of services • Assurance about the quality of care • Learning culture where ideas and good practice are celebrated and shared • Effective partnerships for improvement both within and without the organisation • Openness and transparency • Commitment to training, education, continuous professional development, research and audit • Staff feel valued and supported • Sound knowledge management

21. Clinical and Social Care Governance – first steps • identify a senior professional at board level to provide leadership in relation to clinical and social care governance by 28 February 2003; • designate a committee with responsibility for clinical and social care governance (or in the case of LHSCGs, a sub-group or team) and supporting structures by 31 March 2003; • complete a review/baseline assessment of arrangements within the organisation that identifies clinical and social care governance support systems and systems that require further development by 31 March 2003; and • formulate and agree the organisation’s plan for developing and maintaining effective clinical and social care governance arrangements by 1 May 2003.

22. Clinical and Social Care Governance – next steps • Clinical and Social Care Governance Support Team • Review and feedback on original baseline assessment • Feedback on demonstration inspection • Update on baseline assessment

23. 2002/03 agenda • Adopting a common model for risk management- AS/NZS 4360: 1999 • Putting the fundamental structures and processes in place - HSS (PPM) 3/2002 and HSS (PPM) 10/2002 • Development of initial controls assurance standards • HPSS (Quality, Improvement and Regulation) (NI) Order 2003

24. 2003/04 agenda • Making risk management a functioning reality • Mid-term self-assessment • HPSS governance and risk management adviser • Website development • Launch of initial controls assurance standards • Working towards compliance • Further controls assurance standards • Clinical & Social Care Governance baseline • Drafting of Care Standards

25. 2004/05 agenda • Building general capacity and specific expertise • Multi-disciplinary engagement • HPSS C&SC Governance Support Team • Update on C&SC Governance baseline assessment • Harmonisation of overall approach to governance • Co-ordinated approach to learning & development • First formal reporting on compliance with controls assurance standards

26. Summary • 2002/03 – establishing the legislative framework and putting the fundamental structures and processes in place • 2003/04 – making risk management/controls assurance a working reality and conducting a baseline assessment for clinical and social care governance • 2004/05 – building general capacity, developing specific expertise and engendering multi-disciplinary engagement

27. So how does all of this fit together?

28. The governance mechanisms Statutory Duty of Quality Regulated Care Standards Service Development Frameworks Standards and Guidelines Controls Assurance Standards Inspection Audit Self-Assessment Professional Peer Review Performance Assessment Risk Management Clinical and Social Care Governance Regulation of the Professions Lifelong learning (CPD) Focus on the user

29. What are we trying to achieve?

30. Finance Clinical and Social Care Organisation HPSSRIA Organisational Characteristics Lack of vision Poor objectives Risk ignorant Risk averse Process driven Self-protective Blame culture Inward looking Silo mentality Lack of information Organisational Characteristics Clarity of vision Strategic objectives Risk aware Risk/opportunity Outcome focused Open Learning culture Outward looking Corporate team Sound knowledge management Duty of Quality C & SC Governance Good Governance Risk Management Controls Assurance Standards Regulated Care Standards C&SC Governance standards