Strategic Leadership for Clinical Governance

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					   Strategic Leadership for Clinical Governance

Clinical Governance             Action                                                  Lead                                Date      Links to
Element                                                                                                                               other sections
Clinical Governance : An        To provide clarity around understanding of              Di Caulfeild- Stoker
Overview                        “reasonable assurance”

Almost at average with 3@t      To provide regular reports to the Board and PEC         Di Caulfeild-Stoker David Finch &
most confident                  that monitor the extent of clinical governance          Andy Neil

                                To ensure that the Board and PEC are aware of           Christina Murphy
                                quality and safety issues within commissioned

Section 3                       To ensure closer integration and understanding          Tom Coffey                          Sept
                                between the Board and PEC members by:                                                       2004
The Board and PEC Roles              Re-launching the PEC and non-executive
in Providing Strategic                   Buddy Scheme
                                     Providing a rota to enable non-
                                         executives to attend PEC meetings
Just below average for high
scoring section with 3@T
again most confident.           To ensure that the PEC is able to fulfil its function   Tom Coffey
Suggestion of PEC/NED           as the clinical powerhouse of the PCT
disconnect                             To reorganize the PEC agenda to enable
                                           ample time for necessary discussion and
                                       To create understanding and Trust
                                           between PEC members so that the
                                           committee can oversee due processes of
                                           sub-committees but does not require
                                           every detail
                                       To engage the PEC in clinical
                                           governance plans and actions to ensure
                                           that the plans are fit for purpose
Section 4                       To build on the communication objectives for            Yvonne Connolly and Clinical        ongoing
                                clinical governance to ensure that consistent and       Governance Leads
Fostering Ownership of          user friendly formats, foster understanding of
Clinical Governance             clinical governance across the PCT.

Almost at average with          To explore adapting the Whiteboard approach or          Yvonne Connolly /Stephen Warren/    April
reasonable levels of            other methods to be more applicable to non clinical     Tony Griffiths                      2004
confidence re: strategy (with   teams and independent contractors (dentists,
outliers) and majority          pharmacists and optomotrists
confidence in quality culture
but with some PEC and
NED concerns
Clinical Governance              Action                                                  Lead                                Date      Links to
Element                                                                                                                                other sections
Section 5                        Implement the PPI and commissioning project -           Colin Smith/ Sian Job                         Section 18 Clinical Governance and the
                                   WHIFY (How was it for you?)                                                                         Services Commissioned by the PCT
The Patient Experience
                                 Present information back to Commissioners               Colin Smith/ Sian Job
Marginally above average
despite wide variance of         Evaluate how Commissioners are responding to            Colin Smith/ Sian Job
views re: all questions          Issues raised (i.e. how is PPI affecting
                                 commissioning decisions)
Section 6                        PPI Project Group to score questions posed by           Colin Smith
                                 Strategic Leadership for Clinical Governance
Patient & Public Involvement     programme. Actions will then be drafted that
                                 include issues around communication with the PEC
At average for challenging       and Board as well as specific actions for the PPI
section with wide variance       team.
(including within 3@T) re:
strategy for public
involvement but more
consensual concern re:
active engagement of
patients and carers

Section 7                        To gain maximum feedback from the public via the        Di Caulfeild-Stoker David Finch &   ongoing   Section 6 Patient and Public Involvement
                                 lay representatives on committees, the Patient          Andy Neil
External Scrutiny of Clinical    Forum and through the Overview and Scrutiny
Governance                       Committee of the Council

Below average due to wide        To establish reporting criteria for all external        Di Caulfeild-Stoker David Finch &   ongoing
variance re: SHA                 assessments to go to the Clinical Governance and        Andy Neil
performance measurement          Risk Committee and subsequently the Board and
criteria (and note PEC ‘don’t    PEC (NHSLA Healthcare Commission etc)
know’s’) and re: LA OSC
with low scores some NED’s
and some PEC

Section 8                             To finalise the Clinical Governance Strategy       Di Caulfeild-Stoker David Finch &   Dec       Section 9 Intelligent Information
                                      and to ensure that this is fully integrated with   Andy Neil                           2004
Co-ordination and alignment           other Strategy work within the PCT

Marginally below average              To ensure that links are strong between            Di Caulfeild-Stoker David Finch &   Dec
despite broad confidence re:          pillars of clinical governance and that this is    Andy Neil                           2004
explicit priorities – but less        demonstrated through a coordinated approach
confidence (and significant           to project work
‘don’t knows’) re: evidenced
Clinical Governance              Action                                                Lead                           Date      Links to
Element                                                                                                                         other sections
Section 9                        Establish a robust benchmarking system, which         Christina Murphy
                                 can produce timely information for reporting to the
Intelligent information and      Board and PEC.
Clinical Governance
                                 Raise awareness of the intelligent information that   Christina Murphy
Below average for key            can be derived from data collected relating to
section due to wide variance     patient activity and encourage clinicians and
(including within 3@T) and       managers to make use of it.
some significant concerns
re: adequacy of public           Ask the PEC and the Board to specify their            Christina Murphy
health, provided and             individual information requirements.
commissioned care data

Section 10                       To work with services to ensure that patients and     Yvonne Connolly                April     Section 6 Patient and Public Involvement
                                 their carers are more actively engaged in risk                                       2005
Risk Management                  management systems and processes

Marginally below average for     To consider ways of improving current reports to      Yvonne Connolly                ongoing   Section 9 Intelligent Information
high scoring section with        the Board and PEC so they are informed about all
overwhelming majority            risk issues and particularly around progress
confidence in strategies to      towards engaging patients and carers
promote patient and staff
safety but with broadly
common recognition of need
more actively to engage
patients and their carers with
this agenda (note PEC
‘Don’t knows’ re: this issue

Section 11                       Use development of contracts for Independent          Fiona MarleyM/Doug Middleton
                                 contractors as a means of developing systems to
Clinical accountability and      support and improve practice in primary care
                                 Improve systems for clinical supervision for nurses   Di Caulfeild-Stoker
Significantly below average
with interesting variance re:    Ensure that systems for dealing with poor
accountability and support       performance are consistent across the PCT
for GP’s and large number
of PEC ‘Don’t knows’ re:
Dentists, Pharmacists and
Optometrists and GMS

Section 12                         To engage the Board and PEC in identifying the      Yvonne Connolly                ongoing   Section 15 Clinical Effectiveness
                                   Clinical audit priorities and how they can be
Clinical Audit                     supported
                                   Develop a reporting structure for completed         Yvonne Connolly                April
Significantly below average        audits (so Board and PEC are fully aware)                                          2004
for challenging section with       Improve ways of mapping the improvements            Yvonne Connolly                April
majority of PEC ‘Don’t             coming from clinical audits via the Clinical                                       2004
Know’s re: strategy and            Governance database
Clinical Governance            Action                                                 Lead                                 Date   Links to
Element                                                                                                                           other sections
evidence of audit led change     To develop the concept of Audit as a means of        TBA
                                 mapping the whole patient journey particularly
                                 with relation to long term conditions
Section 13                     Integrate planning processes to ensure that clinical   New Planning Manager
                               and non-clinical training needs and organizational
Education and Training         priorities are integrated into the Training Needs
Marginally above average
for challenging section        To ensure that there is a direct relationship          Annette Bygraves
despite wide variance re:      between the Knowledge and Skills Framework,
strategy but majority          required competencies and staff Personal
confidence in response to      Development Plans PDPs This will ensure that the
needs of clinical and          organization is fit for its purpose.
managerial/administrative      To ensure that the Board and PEC are fully             Annette Bygraves
staff                          engaged in planning the Training and Development
                               priorities of the PCT
Section 14                      Research and Development Committee to                 Amy Scammel/Andy Neil
                                consider ways of improving communication with
Research Governance and         the Board and PEC through the R&D Strategy
Research Implementation
                                  To work with the Medicines Management Group         Yvonne Connolly/ Alastair Johnston          Sections 12 &15 Clinical Effectiveness and
Marginally above average          to monitor compliance with NICE Guidelines                                                      Audit
for challenging section
despite significant NED
concerns re: corporate
ownership of the agenda
and wide variance of views
re: evidence of NICE
Clinical Governance             Action                                               Lead                                    Date   Links to
Element                                                                                                                             other sections
Section 15                         To use the QUMAS data to enable further           Yvonne Connolly and Locality Clinical          Section 9 Intelligent Information
                                   development of effective treatments for chronic   Governance Facilitators
Clinical Effectiveness             disease in primary care

                                   To further develop the Clinical Governance        Yvonne Connolly                                Section 12 Clinical Audit
                                   Database so that as a means of reporting on
                                   and spreading good practice

                                   To ensure that NICE guidance is Disseminated      Christina Murphy                               Section 14 Research Governance and
                                   to relevant leads across the PCT                                                                 Development

                                   To consider initiatives that enable concordance   TBA
                                   issues to receive a higher profile

Section 16                      To agree a process for supporting teams to           Anna Byrne
                                consider new ways of working as an alternative to
Staffing and Staff              requesting increased staffing. Bids will only be
Management                      considered once this has been carried out.

At average despite wide         To provide regular information to the Board and      Anna Byrne
variance re analysis of staff   PEC of all OD/HR/Training activity to ensure staff
fitness for purpose and         development issues are highlighted at strategic
adequacy of managerial and      level
administrative infrastructure
                                To use the staff development report to target        Anna Byrne
                                development in areas that are not performing.

Section 17                      Improve health intelligence to inform planning and   Salman Rawaf                                   Section 9 Intelligent Information
Clinical Governance and the
PCT’s Public Health             Development of a commissioning framework which       Salman Rawaf                                   Section 18 Services Commissioned by the
Function                        focuses on the make-up of the local population                                                      PCT

Significantly below average     Development of a prevention framework to reduce      Salman Rawaf
due to massive variance re      and delay the on set of ill health and disease and
impact of public health         promoting mental health and well-being.
understandings on provided
and commissioned services       Monitoring and Evaluation to improve health and      Salman Rawaf
(and note a focus for the       service delivery
new Healthcare

Section 18                      Provide regular commissioning information to the     Christina Murphy
                                Board and PEC. This information should include
Clinical Governance and the     issues raised by patients, Heathcare Commission
Services Commissioned by        reports and other sources.
the PCT
                                Ensure that patients and the public are actively     Christina Murphy                               Section 6 Patient and Public Involvement
Marginally below average on     engaged in the Commissioning process
challenging section despite
Clinical Governance              Action                                                  Lead                             Date   Links to
Element                                                                                                                          other sections
moderate majority                Ensure that quality issues are at the centre of the     Christina Murphy                        Section 9 Intelligent Information
confidence re corporate          commissioning process and that information is
ownership of the agenda.         developed that can measure that this is the case
Note extreme variance re
extent of PEC/CG
Committee engagement with
commissioning, majority
concern re public
engagement with this
agenda and PEC 'Don't

Section 19                       Ensure that commissioning processes support the         Christina Murphy
                                 development of pathways across boundaries
Inter-organisational             Ensure the commissioning process is informed and        Christina Murphy/ Salman Rawaf          Section 17 the PCT’s Public Health Function
Elements of Clinical             shaped by public health led understanding of local
Governance                       need
                                 Engage public health in commissioning forums            Christina Murphy/ Salman Rawaf
Just below average for high
scoring section due to some
NED and PEC concerns re
strategy and effectiveness of
relationships with social care
and voluntary sectors

Section 20                       To ensure that General Dental Practice. Are             Stephen Warren
                                 supported by PCT systems such as those for
Additional PCT                   infection control with the collaboration of the GDPs
Responsibilities                 and support of the LDC.

Well above average for           To work to ensure that there is equity of standards     Stephen Warren
challenging section due to       for quality across the PCT for dentists, optomotrists
majority confidence in           and pharmacists.
strategy for engagement of
dentists, pharmacists and        To ensure that independent contractors are              Stephen Warren
optometrists and in their        encouraged to report incidents via the PCT incident
representation on PEC            reporting systems