REMUNERATION & TERMS OF SERVICE COMMITTEE

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					              NORTH WEST AMBULANCE SERVICE NHS TRUST

     CLINICAL GOVERNANCE SUB-COMMITTEE TERMS OF REFERENCE


1.     Constitution

1.1    The Trust Board hereby resolves to establish a Sub-Committee of the
       Board to be known as the Clinical Governance Committee (The
       Committee). The Committee is a non-executive committee of the Board
       and has no executive powers, other than those specifically delegated in
       these Terms of Reference.

2.     Remit and functions of the Committee

2.1    The Committee is established to oversee all Clinical Governance
       activities within the Trust, including those clinical activities which incur
       risk, for which the definition of risk shall be:

       “The identification, understanding and control of all challenges to the
       assets or activities of the Trust to enable it to perform its stated
       functions and responsibilities.”

2.2    The main functions of the Committee are: -

          •   To monitor the progress of the Trust’s Clinical Governance
              strategy (including Clinical Effectiveness, Clinical Audit and
              Research & Development) and where appropriate make
              recommendations for change.

          •   To identify areas of clinical risk and ensure their inclusion in the
              Corporate Risk Register. To monitor and make
              recommendations to mitigate these risks and advise the Risk
              Management Committee accordingly.

          •   To receive, review and recommend to the Trust Board, all
              Clinical Governance related strategies and policies.

          •   To receive and review Clinical Governance related internal and
              external reports and, where appropriate, make recommendations
              for change.

          •   To receive and review the Trust's Clinical Governance
              Development Plan and, where appropriate, make
              recommendations for change.

          •   To regularly receive and review Clinical Governance reports
              which will be used as the basis for the Trust’s Annual Clinical
              Governance Report.


APPROVED BY TRUST BOARD:                Draft                     Page 1 of 4
REVIEW DATE:                            Draft
                                                                                ITEM 6.6
         •    To receive and recommend to the Trust Board the Trust’s Annual
              Clinical Governance Report.

         •    To receive and review reports of all significant untoward incidents
              involving clinical practice and, where appropriate, make
              recommendations for change.

         •    Agree and review the Trust's annual Clinical Audit Plan and,
              where appropriate, make recommendations for change.

         •    Monitor the Trust’s Children’s Healthcare Provision, inclusive of
              child protection issues and, where appropriate, make
              recommendations for change.

         •    Monitor Trust wide progress against the Caldicott performance
              standards and, where appropriate, make recommendations for
              change.

      General
        • To be updated on clinical governance-related incident reports
           and any ongoing Civil or Criminal actions against the Trust.

         •    To provide a summary report and recommendations from each
              meeting to the Audit Committee outlining key issues, actions and
              timescales.

         •    To undertake any other activity as directed by the Trust Board.

         •    To ensure that appropriate clinical audit mechanisms are
              implemented to ensure that all Trust clinical activities are audited
              annually or at any other time as directed by statutory
              requirements or the Committee.

3.    Composition and conduct of the Committee

3.1   The Committee shall be appointed by the Board and will comprise: -

             Medical Director (Chair)
             Director of Finance
             Locality Director (Cheshire & Mersey)
             Locality Director ( Cumbria & Lancashire)
             Locality Director (Greater Manchester)
             Assistant to Chief Executive

      In the event that the Chair of the Clinical Governance Committee is
      unable to attend a meeting, the members present shall decide upon a
      Deputy Chair to conduct the meeting in his/her absence.

      Informed deputies may attend in the absence of a Committee Member.

APPROVED BY TRUST BOARD:              Draft                    Page 2 of 4
REVIEW DATE:                          Draft
                                                                             ITEM 6.6
3.2   Other officers of the Trust may attend at the request of the Committee
      to present and give clarification on issues which require a decision from
      the Committee but may not vote on decisions.

3.3   Quorum
          No business shall be transacted unless at least 3 members are
          present.


3.4   Notice of meetings
           Before each meeting, a notice of the meeting specifying the
           business proposed to be transacted, and signed by the Chairman
           or by an officer of the Trust authorised by the Chairman to sign on
           his behalf, shall be sent by post to the usual place of residence of
           each member, so as to be available to him at least three clear
           days before the meeting.

3.5   Frequency of meetings
          The Committee will normally meet on a two monthly basis.
          However, the Chair may call a meeting at any time provided that
          notice of the meeting is given as specified above.

3.6   Minutes
          The minutes of meetings shall be formally recorded by the
          Corporate Secretary, or a member of the Governance Support
          Team, checked by the Chair, and submitted for agreement at the
          next ensuing meeting where they will be signed by the person
          presiding at it.

           The minutes of meetings shall be submitted to both the Audit
           Committee and the Board. The Chair of the Committee shall draw
           to the attention of the Audit Committee and the Board any issues
           that require disclosure or require executive action.

3.7   Emergency Powers
          The Chair and the Director of Finance may, in an emergency,
          exercise the functions of the Committee jointly. A full report should
          be prepared as for the Committee and a signed authorisation
          appended. The exercise of such powers together with the report
          shall be submitted to the next formal meeting for ratification.

3.8   Other Matters
          The Committee shall be supported administratively by the
          Corporate Secretary, or a member of the Governance Support
          Team, whose duties in this respect will include:

              •   Agreement of agenda with the Chair and attendees and
                  collation of papers.
              •   Taking the minutes.
              •   Keeping a record of matters arising and issues to be carried

APPROVED BY TRUST BOARD:             Draft                   Page 3 of 4
REVIEW DATE:                         Draft
                                                                           ITEM 6.6
                  forward.
              •   Advising the Committee on pertinent areas.

4.    Delegated Authority

4.1   The Committee is authorised by the Board to:-
         • Investigate any activity within its Terms of Reference.
         • Seek any information it requires from any employee and all
           employees are directed to co-operate with any request made by
           the Committee.
         • Obtain outside legal advice or other independent professional
           advice and to secure the attendance of outsiders with relevant
           experience and expertise if it considers this necessary.

5.    Relationship with and reporting to the Board

5.1   The Committee will report in writing to the Board the basis for its
      recommendations. The Board will use that report as the basis for their
      decisions but would remain accountable for taking the decision. Minutes
      of the Board’s meetings will record such decisions.




APPROVED BY TRUST BOARD:            Draft                  Page 4 of 4
REVIEW DATE:                        Draft
                                                                         ITEM 6.6

				
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