"IBoard self assessment"
BOARD SELF-ASSESSMENT – NOVEMBER 2009 This paper presents the results of the Board self assessment undertaken in November 2009. The self assessment was designed to give Board members the opportunity to reflect on the operation of the Board and highlight areas of good performance and those for further development. The results relate to the World Class Commissioning “Governance – Board and to the Use of Resources Key Line of Enquiry 2.3 “Does the organisation promote and demonstrate the principles and values of good governance”. The details of the results are attached in Appendix 1. Conclusions Good performance is shown in the following areas: Annual business cycle Provision of training for Board members Receipt of minutes from committees for which it is responsible thus ensuring an accountability line That all members of the Board are confident that they can constructively challenge colleagues, demonstrating a mature Board in operation A clear sense of corporacy among Non-Executive and Executive members, again demonstrating maturity The PCT has clearly defined its strategic aims That all Board members play an active role in shaping strategy and spends sufficient time on strategic issues That the Board has been active in prioritising areas and timing of investment, and trade-offs involved That the Board has responded well to problems over the past year The risk processes, including the BRAF, at Board level work well for PCT risks That it has considered how integrated governance works across various committees That there is clinical input to decision-making Arrangements are in place to ensure probity and propriety Provider governance is adequate, but less certain on monitoring Administrative arrangements are sound Areas for development High priority Making sure that assessment of Board performance continues to take place and that standards are set by the Board against which this can be measured. How the Board reviews risks and risk issues across the activities of its major provider organisations 1 Concerns about joint commissioning and Partnership governance Low priority Ensuring standing orders are reviewed annually Exploring how the Board can improve its horizon-scanning Ensuring that the changes to organisational structure currently underway are made clear to the Board and articulated and delineated More work required on PBC governance to improve awareness Monitoring arrangements for provider governance Improving awareness of the role of SIRO Many of these areas reflect the results of the Governance Committee self- assessment and the Medical Director is undertaking a review of integrated governance arrangements is his new role as overall “lead” for governance. It should be noted that one Non Executive Director is fairly new and was unable to comment in many areas. Recommendation That the results of the Board self-assessment be considered by the Medical Director, as part of the review of integrated governance arrangements, and in conjunction with the Head of HR and Organisational Development, as Organisational Development lead and lead for Board development. Derek McAuley Assistant Director Corporate Governance and Risk 27 November 2009 2 Appendix 1 RESULTS – based on 10 responses (6 NEDs; 4 Execs) Q No. Issue Yes No DK Comments/action Composition, Establishment and Duties 1. Are Standing Orders used to 111 1 guide the work of the Board? 111 111 2 Are Standing Orders reviewed 111 1 11 annually to take into account 111 governance developments? 1 3 Has the Board established a 111 Business cycle circulated with plan (business cycle) for the 111 Board papers. conduct of its own work across 111 the year? 1 4 Are members provided with 111 Need board development session sufficient training 111 still. opportunities? 111 Adequate opportunity for courses. 1 5 Does the Board ensure that 111 11 More visits around the patch members have sufficient 111 needed. knowledge of the organisation 11 to identify key risk areas? 6 Does the Board have a 111 1 11 But could be improved – not mechanism to keep it aware of 111 enough horizon scanning. topical, legal and regulatory 1 Not a formal mechanism. issues? In theory via governance but needs restructuring (via Rajan) Issues that become topical for any reason are discussed formally and/or informally. Eg CEO report, Board strategy sessions. 7 Does the Board ensure that it 111 But ignores them. Not taken receives regular reports or 111 seriously and issues from them minutes of the committees for 111 never discussed. I suspect most whom it is the “parent” body? 1 Board members don’t read them. 8 Has the Board reviewed if the 111 1 11 Not explicitly. reports it receives are timely 111 Often to some extent – often an and have the right format and 1 executive decision. content to ensure its Via Governance. responsibilities are Board critically reviews all reports. discharged? I’m not sure that we do it formally within a framework suggested by the question. Eg Recent Board development diagnostic identified need for a CE report etc 9 Are members of the Board 111 confident to constructively 111 challenge colleagues? 111 1 10 Does the Board assess its own 111 11 11 Not systematically/explicitly. 3 effectiveness periodically? 111 This process is a start. Not enough. Informally and by diagnostic in January 2009. 11 There is a clear sense of 111 Board corporacy amongst non 111 executive and executive 111 members 1 12 The Board has set standards 111 111 11 Not clear enough. against which its performance 1 1 No for Board’s own performance can be measured? (but yes for PCT performance targets) Strategy 13 The PCT has clearly defined 111 its strategic aims and 111 objectives 111 1 14 The PCT has clearly 111 1 1 More work needed; possibly articulated values that have 111 through SOSF. been consistently articulated to 11 Yes in theory. stakeholders? The PCT has been highly successful in engaging with stakeholders. 15 Do you consider that the PCT 111 1 But needs review as we go into has a clear and well-defined 111 SOSF; not sure it is fit for that organisational structure? 111 purpose. No, only because major change is currently happening. 16 Do you consider that the 111 11 As see above organisational structure of the 111 Major change happening PCT is well understood by the 11 Board? 17 Do you consider that the roles 111 111 11 Not anymore as changes of exec and accountabilities within the 11 directors/MCH separation. organisation are clearly To some extent, but these often articulated and delineated? seem to change. Major change happening. No but it’s a complex model. 18 The entire Board play an 111 active role in shaping 111 strategy? 111 1 19 The Board spends sufficient 111 1 I suspect best practice is for a time on strategic issues? 111 greater % - interested to know 111 how we benchmark against other PCTs? Additional time allocated for this purpose. 20 The entire Board play an 111 1 active role in prioritising areas 111 and timings of investment? 111 21 The entire Board play an 111 1 But more needed active role in making 111 4 investment trade-offs? 111 22 The criteria used to make 111 1 Being work on further as part of these trade-offs and the 111 SOSF rationale for the priorities is 111 clear to Board members? 23 Has the Board responded well 111 Eg Financial challenge/PBC to any problems or crisis that 111 developments/MCH separation. have arisen in the last year? 111 Latterly it has. 1 Board’s been well tested this year – determined to resolve major issues. Integrated Governance 24 The Board reviews risks and 111 1 Very clear process. risk issues across its own 111 RAF reviewed regularly. activities adequately? 111 25 The Board reviews risks and 111 111 11 We need to focus on our business risk issues across the activities 1 1 and not be drawn into other of its major provider providers operational issues. organisations adequately? However we are minded about the impact on other providers of PCT decisions. Not as a Board, most likely to be done in Governance Committee. Needs reviewing for partners. Of increasing concern, we are addressing these issues at every Board meeting. 26 The Board is involved in 111 1 prioritising and managing all 111 major risks, including 111 mitigating actions? 27 Has the Board considered how 111 1 Not well enough. it integrates the work of the 111 Certainly to my knowledge by a various committees around 111 meeting of the respective Chairs governance eg Audit, of those Committees. Governance and Provider Ongoing but needs to be revisited Committees? as part of governance. Work continues on this matter. A meeting has been convened to explore options and identify best practice. 28 The Board has a process for 111 1 1 It does for medical (GP input). ensuring appropriate clinical 111 The new CCE ie reconfigured input into its decision-making 11 PCE etc, PBC chairs processes? 29 An integrated assurance 111 1 1 system is in place covering 111 quality, activity and resources 11 and aligned to national and local targets and priorities? 30 The Assurance Framework 111 1 fully reflects the significant 111 areas of business risk facing 111 the organisation? 5 31 Decision-making within the 111 1 Not enough or timely PCT governance structures is 111 supported by intelligent 111 information? 32 Arrangements are in place 111 which promote and ensure 111 probity and propriety in the 111 conduct of the Board’s 1 business? 33 Is the Board assured that the 111 1 11 Not yet. PCT’s arrangements for PBC 111 Albeit a development area. governance are adequate and 1 But it has taken a long time. effectively monitored? Yes, matter of major consideration by the Board. Need to keep this under review. New scheme of delegation & accountability agreement 34 Is the Board assured that PCT 111 1 1 Gaps in specialist for example arrangements for 111 commissioning governance 11 are adequate and effectively monitored? 35 Is the Board assured that PCT 111 111 111 CHC is an example. arrangements for joint 1 Strengthening of NWSCT commissioning and arrangements. partnership governance are Not completely. adequate and effectively Partnerships? monitored? 36 Is the Board assured that PCT 111 Needs to be tighter. arrangements for provider 111 Yes, but we constantly look for governance are adequate? 111 opportunities to improve. 1 37 Is the Board assured that PCT 111 11 But still lack of clarity of arrangements for provider 111 relationship between provider and governance are effectively 11 other committees. monitored? Reports need to come to governance systematically. Provider Committee reports quarterly to the Board. 38 Are you aware of the role of 111 11 1 But only 2 weeks ago! the Senior Information Risk 111 I’m not sure of this specific post. Officer? 1 Now will be medical director. Administrative Arrangements 39 Are papers and minutes 111 But much less paper and focus on circulated in good time for 111 part b discussion would be good. members to give them due 111 Board receives papers 1 week consideration? 1 before meetings 40 Does the Board meet the 111 12 meetings a year. appropriate number of times to 111 deal with planned matters? 111 1 6