An Organisation-wide Policy for the Management of External Agency Visits, Inspections and Accreditation Responsible Directorate:
Corporate Services
Responsible Director:
Helena Corder
Date Approved: Committee:
8 August 2008 Governance Committee
Version control Document Title Document Number Author Contributors Version Date of Production Review date: Per responsible for revision Primary Circulation List Web address Restrictions
Management of External visits 1 Terry Service See section 13 1 10 June 2008 August 2010 Terry Service www.kirklees-pct.nhs.uk None
Standards for Better Health map Domain: Core Standard Reference:
1 – Safety, 3 – Governance, 4 – Patient Focus C1 (a), (b). C7 (a), (b). C10 (a), (b). C11 (a),
Performance Indicators:
1. Exception reports 2. Performance Advisory Group Minutes 3. Decision Making Group Minutes (as necessary)
Contents
Section 1 2 3 4 5 6 6 6 6 6 6 7 8 9 10 11 12 13 Appendices A B C
Policy Statement Introduction Associated policies and procedures Aims and Objectives Scope Accountabilities a) Board accountability b) Committee c) Senior Management Team d) Appointed Lead e) Project Manager Consultation with Stakeholders Procedure for managing assessments Equality Assessment Training Needs Analysis Monitoring of compliance Standard Definitions Stakeholder
Page 2 2 2 2 3 3 3 3 3-4 4 4 4-5 5-6 6 6 6-7 7 7
Lead Director and Committee reporting Report Template Equality Assessment tool
8 9 10
Page 1 of 11
1.
Policy Statement
This policy aims to provide a framework for the co-ordination and evaluation of recommendations arising from external agency visits, inspections and accreditations. The framework includes a process for disseminating and performance managing the implementation of actions arising from the recommendations and providing assurance to the Board. 2.
Introduction.
This process allows for good co-ordination and evaluation of the work of External Agency visits, Inspections, Accreditations and Internal Control processes, which will bring increased benefits to both the organisation and the Review Bodies. It is designed to help minimise the burden on the organisation by reducing overlap and allows potential gaps in assurance to be identified and addressed. It is seen as part of the organisation’s control system and provides assurance to the Governance, Audit; Finance and Performance, PEC on behalf of the Trust Board. This will enable the Trust, wherever possible, to make use of the work of the many External Reviewers, and ensure the whole process is efficient. 3.
Associated Policies and Procedures.
This document should be read in accordance with the Trust’s following policies, procedures and guidance. • • • 4.
Policy for the Development of Policies and Procedural Documents Media Handling Policy Risk Management Strategy Aims and Objectives.
1. Identify the management responsibilities for Management of External Agency Visits, Inspections and Accreditation. 2. Ensure that adequate resources and priorities are applied to the inspection process. 3. Ensure that good project management processes are used o manage the inspection process. 4. Provide a process that ensures actions resulting from the inspection are appropriately reported and action taken as a result. 5. Ensure that there are processes in place to performance manage any action plans or recommendations.
Page 2 of 11
5.
Scope of the Policy / Procedure
This policy must be followed by all NHS Kirklees employees and staff on temporary or honorary contracts as well as bank staff and students. 6.
Accountabilities & Responsibilities
a).
Board responsibility.
The Chief Executive has overall responsibility with regard to external agency visits, inspections, accreditations, and internal control processes. This responsibility is delegated to the Director of Corporate Services or the Director of Patient and Professions (depending in the type of assessment). Both posts are nominated Directors for ensuring there is a co-ordinated approach to any inspections or reviews undertaken in the organisation. Following each visit/inspection, the Governance Committee and ultimately the Board will receive a report and action plan for implementing any recommendations arising from the visit and progress reports to provide assurance that actions have been implemented and that the system is working effectively. b).
Committee with Overarching Responsibility for Management of all External Agency Visits, Inspections and Accreditations
The Governance Committee will have overall responsibility for the management of all external agency visits, inspections and accreditations. The Committee will: 1) Confirm the accountable committee for specific visits etc 2) Keep the policy under review to ensure continuous development 3) Receive a summary report of all visits etc and approve the action plans to address the recommendations. 4) Report through to Board on general progress or areas of concern 5) Ensure, through the SMT lead, that any lessons to be learnt are identified and implemented c).
Lead Senior Management Team member with Responsibility for Specific External Agency Visits, Inspections and Accreditations
The Chief Executive will identify and appoint a Director lead for specific external agency visits, inspections and accreditations. The role of the director will be to: 1) Identify an appropriate lead for the review to co-ordinate the process 2) Ensure that adequate resources and priorities are provided for the nominated leads and staff 3) Review and evaluate the report and oversee the development of an action plan to address the recommendations 4) Provide a response to the external agency Page 3 of 11
5) Report to the Governance Committee and ultimately the Board. d).
Appointed Lead for All External Agency Visits, Inspections and Accreditations
The nominated leads for any external inspection have a number of specific tasks namely; 1) Maintaining a schedule of review dates (external agency visits, inspections and accreditations); 2) Maintaining action plans to implement any recommendations made as a result of reviews; 3) Ensuring action plans are reviewed regularly and evaluated by the nominated committee/group; 4) Liaising with the nominated/appointed lead for each specific external agency visit, inspection or accreditation; 5) Ensuring that the organisation-wide risk register is populated with risks identified from external agency visits, inspections and accreditations 6) Nominate a project with the specific skills, experience and authority to manage the inspection process. e).
Project Managers role
The lead project manager’s role is an important position in the successful management of an external inspection and therefore have a number of key tasks; 1) Support the process of the visit – liaison, briefings, programmes, evidence, collation, interim reports/briefings etc; 2) Provide a summary briefing of the initial findings of the specific external agency visit to the identified committee/group, highlighting any areas identified as being high risk or media interest; 3) On receipt of the report following the specific external agency visit, inspection or accreditation, ensure that all the information included in the report is accurate and complete. 4) Carry out risk assessments for activities identified in the report recommendations, and as appropriate enter on the risk register; 5) Develop a report and an action plan to address any recommendations made to the appropriate committee who will determine the frequency of monitoring of progress with the action plan 7.
Consultation and communication with stakeholders
Any external inspection or evaluation of the Trust will require the involvement of key stakeholders including other NHS organisations, local authorities or lead organisations such as NHS Yorkshire and Humber. To ensure that all relevant stakeholders are involved a member of the Senior Management Team will:
Page 4 of 11
1) Identify the relevant stakeholders for each specific visit, inspection or accreditation 2) Ensure that appropriate stakeholders are given advance notice of any planned visits, inspections and accreditations as appropriate 3) Consider stakeholder involvement in the visit/process 4) Consider the communication requirements including agreed responses. 5) Ensure that stakeholders are advised of the outcome of the visit. 8. Procedure to follow for an external inspection 1. Once a visit is announced the Chief Executive will identify a Director lead to oversee the visit and ensure that arrangements are in place and details of the visit are communicated as appropriate. 2. The Director will nominate a senior manager to co-ordinate the inspection programme and ensure that appropriate resources and priorities are attached to the task. 3. The senior manager will nominate a project manager with the relevant, skills, experience and time to manage the process and produce and initial plan including stakeholders, timescales, resource requirements, key indicators and communication requirements. 4. Any projected gaps in the plan will be discussed with the Director and if necessary, noted on the Trust risk register. 5. The project manager will ensure that all actions are noted and included within the programme and key indicators are met within specified timescales. 6. Following the visit, the Senior Manager will be responsible for receiving, and responding to the report and evaluating the recommendations. 7. An action plan will be developed to ensure that all relevant and appropriate recommendations are implemented using the template at Appendix A. 8. The report will be received and the action plan approved by the Governance Committee. 9. The Director will be responsible for identifying the relevant service areas and for performance managing the implementation through the appropriate committee. 10. The Director will present regular progress reports to the Governance Committee. The Director of Corporate Services will be responsible for ensuring that there is a centrally held, internally audited record of all external agency visits,
Page 5 of 11
inspections and accreditations together with their reports which is kept updated and monitored within specified timescales. 9.
Equality Impact Assessment.
All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This policy and procedure were found to be compliant with this philosophy. 10.
Training Needs Analysis.
Training is only necessary for staff who perform the duties laid out within this document and are intrinsic within job descriptions and person specifications. No training is required for any other staff member. . 11.
Monitoring Compliance with this Policy and Procedure.
This policy will be reviewed every two years as part of the policy management programme. Part of the process of managing external inspections and accreditations involves the reporting of findings to the Governance Committee. Within these reports the author will report the effectiveness of the policy including the agreed plan, methodology and compliance with indicators. The governance Committee will advise on any changes required to the policy and procedure which are noted as a direct result of the external inspection. The lead director is responsible for ensuring that any necessary changes are made to the policy or procedure and that these changes are enacted. Key indicators used within the process will include; •
Identification of key personnel including lead director, senior manager and project manager.
•
Identification and allocation of sufficient resources and priorities.
•
Key indicators including timescales adhered too.
•
Report provided to Governance Committee with recommendations.
•
Action plan produced with identified leads, objectives and key performance indicators. Page 6 of 11
•
Risk register populated where necessary.
12.
Definitions
Visits, Inspections and Accreditations: For the purpose of this policy ‘visits, accreditations and inspections’ refers to those visits where there are likely to be organisational and strategic implications. Informal visits and those to review operational aspects of a service or department need not be managed by the process described in this policy. Where there is any doubt advice should be sought from the Director of Corporate Services or the Director of Patient and Professions. External Agency: This would include statutory and non-statutory bodies with a legitimate interest in the Trust and with whom NHS Kirklees is expected or requested to co-operate Accreditation: Provides independent assurance from a third party that the organisation has achieved a level of compliance with an agreed set of criteria/standards. Inspection: Describes the role of statutory bodies with a remit specific to healthcare to assess and report on the performance of the organisation Internal Control: Systems, procedures and behaviours by which the Trust controls its functions in order to achieve organisational objectives, safety and quality of services 13.
Key Stakeholders consulted / involved in the development of the policy & procedure. •
Helena Corder - Director of Corporate Services
•
Sheila Dilks - Director of Patient and Professions.
•
Terry Service - Assistant Director of Corporate Services and Risk Management
•
Sue Smith - Assistant Director of Clinical Governance and Standards.
•
Jane Kennedy - Litigation and Investigation Manager
•
Policy Development Group
Page 7 of 11
Appendix A Lead Directors and Committees External Agency
Executive Committee
NHSLA
Governance Committee
Audit Commission
Finance and Performance
Patient Environment Action Team Health and Safety Executive
Board Governance Committee
Royal Colleges
PEC
Health Care Commission
Governance
Fire Service
Governance Committee
Environment
Governance Committee
Security Management
Governance Committee
Fraud and Corruption (CFSMS) Serious Untoward Incident
Finance and Performance
Confidential Enquiries Internal Audit External Audit Complaints Claims investigations Ombudsman Investigations Professional Body investigations (GMC, GDC, NMC, GOC & RPS)
Governance Committee Governance Committee Finance and Performance Finance and Performance Governance Committee Governance Committee Governance Committee
Nominated Lead Director of Corporate Services Director of Finance Director of Corporate Services Director of Corporate Services Director of Patient and Professions Director of Patient and Professions Director of Corporate Services Director of Finance Director of Corporate Services Director of Finance Director of Corporate Services Director of Corporate Services Director of Finance Director of Finance Director of Services Director of Services Director of Services
Corporate Corporate Corporate
Governance Committee Director of Patient and Professions
Page 8 of 11
Appendix B Report Template following External Agency visit, inspection or accreditation Action Responsibility Monitoring Recommendations Compliance arrangements Required and (detail all Timescales recommendations (yes/no/partial) from the report
Page 9 of 11
Equality Impact Assessment Tool
Appendix C:
To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)
2. 3.
4. 5. 6. 7.
(including
gypsies
and
Comments
No No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?
No No
No NA NA NA
If you have identified a potential discriminatory impact of this procedural document, please refer it to Human Resources Dept together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources Department
Page 10 of 11