GOVERNANCE SMART objectives / SUHFT board development ... · GOVERNANCE SMART objectives / SUHFT board development programme Specific objective Measurable Success Actions required

GOVERNANCE SMART objectives / SUHFT board development programme

Specific objective Measurable Success Actions required Relevance / Outcome Owner Time

Documented set of Trust Board

objectives will be in place which have

been discussed and agreed by BMs

Board development programme

is aligned to the outcome of

work undertaken by Deloitte LLP

Chair / CEMay board

meeting

Board development sessions, including

attendance, documented

Evidence of BMs commitment to

developmentSec May onwards

Board development session (external

facilitator) to discuss:

- the role of the board and attributes of a

healthy board (in the health sector);

- board to define its own goals and

aspirations (distinct from those of the

organisation) which are aimed at driving

continual improvement of the board

(link to board development session in

objective 7)

BMs will have an appreciation of

the role of the board and NEDs in

an FT environment and will

understand what a good board

looks like.

Chairby end Aug 5th

September

Board education session on the personal

and corporate liabilities of directors

BMs cognisant of the liabilities both

for the board as a whole, and as

individuals

Chair 06/06/2012

Further develop the appraisal process for

individual BMs

Individual objectives are clearly

aligned to those of the board (and

documented)

CE / Chair by end Sept

Prior-board exec meetings to be diarised

every month, with all executives

(including non-voting) in attendance.

More time spent together as a

team will lead to open debate and

challenge key issues whilst execs

become more aware of the work of

colleagues.

CE on-going

Execs to continue with individual and

team coaching.

Increased level of challenge by

execs at board meetings.CE on-going

Develop an on-going process for future

(whole board) evaluation

1

Board Performance

Evaluation (which

includes

implementation of

the Board and

Development

Programme)

Board development programme

in place and allows Board to

constantly track progress

against its objectives

Chairby end Aug 5th

September

The board can demonstrate that

the agreed objectives are used

within the appraisal process for all

BMs.


1) strategy for growth

Board members (BMs) should be

able to articulate the vision of the

organisation

2) risk appetite (29th August 2012 /

RSM)

BMs will have common view on

risk parameters the board is willing

to accept

3) emerging environmental and

organisation issues, their associated

sensitivities, impact and actions,

contingency planning.

BMs will have clearer

understanding of external factors

affecting the organisation

1) environmental and policy landscape /

horizon scanning

At least a third of board meetings

will be spent discussing strategy

Board is able to demonstrate the

link between strategies and

supporting plans. Board

discussion reflects understanding

of integrated structure.

phased

implementation to

conclude by Feb

2013

IT Strategy MD

01/06/2012

tabled again 25

July 2012

to be tabled again

26 Sept 2012

Financial Strategy dittoFD

01/09/2012 Nov

2012

Workforce Strategy ditto DHR Aug-12

Data quality strategy ditto DO Jun-12

Risk strategy ditto CE complete

Estates Strategy ditto DEF Dec-12

Quality Strategy ditto DoN Jul-12

2

Annual Plan 2013 - 14 will be

drawn from embedded vision,

strategies, risk management

structure and BAF.

"No surprises".

Use board development time to discuss:

Increase board

insight and

foresight so that all

board members

play a part in

setting the

organisation's

strategy and

objectives

Development of supporting strategies,

ensuring that they are fully integrated and

aligned to service line reporting to provide

info to support investment / disinvestment

strategies, presented to board, including:

use board agenda to plan strategic debate:

Chair

end Aug

by end Sept

Milestones for delivery in place,

approval dates appear on board

calendar, and specific risks to

implementation on the risk register.

2


Assessment against Monitor's quality

governance framework guidance for new

FT's; results presented at board

Board is aware of areas that

require more attention and is able

to focus resources to those areas

DoN Jul-12

B Quality Strategy approved at Board DoN Jul-12

All quality account priorities to be

included in the board dashboardDoN

01/09/2012

October 2012

Quality appears high on each board

agenda; board tracks quality KPIs each

board meeting and board calendar

reflects rolling programme of review,

including quarterly reporting of risk

register;

Board is sufficiently aware of

potential risks to qualityChair on-going

Board development session:

- core elements of quality governance

- ensure board is aware of governors

involvement in quality

- agreement of top 3 quality priorities

- understand how external benchmarks

are used to assess quality

- review metrics used for board reporting

- reminder of quality governance

processes and structures

- briefing for NED quality walkabouts

- overview of board to ward data process

Board has necessary leadership,

skill and knowledge to ensure

delivery of the quality agenda

DoN Jul-12

3

Trust complies with

Monitor's Quality

Governance

Framework in all

aspects

An assessment of the Trust's

quality governance framework

against Monitor's quality

guidance for new FT's will be

carried out, and results

presented to the Board.

Thereafter, work carried out to

fill residual gaps - see

alongside.

Quality drives the Trust's strategy

3


Self assessment programme to be

agreed

Board has necessary leadership,

skill and knowledge to ensure

delivery of the quality agenda

Chair

Initiated by end

Dec 2012,

completed by end

March 2012 (to

accommodate new

board members)

Review: board clear about process for

escalating quality performance issues to

board (development session)

Jul-12

Establishment of Clinical Audit

Committee - monthly meetings - which

holds business units to account for

clinical governance issues

complete

Quality Assurance Committee - ToR

review (RSM)

Clear roles and accountabilities in

placeSec

end Sept to be

updated as part of

BAF methodology

work Sept / Oct

Trust seeking to appoint NED with clinical

/ patient focus. Recruitment process to

begin.

Chair /

GovernorsJul-12

NED with clinical background to be in

post.

Chair /

Governorsend Nov 2012

Review-board clear about process for

escalating quality performance issues to

board (development session)

Clearly defined, well understood

processes for escalating and

resolving issues and managing

performance

DoN Jul-12

End of Q1 performance against quality

account indicators published for staff and

governors to view.

Board actively engages patients,

staff and other key stakeholders on

quality

DoN end August 2012

3

Trust complies with

Monitor's Quality

Governance

Framework in all

aspects









alongside.

DoN

Independent director on board with

relevant experience.

Clearly defined, well understood

processes for escalating and

resolving issues and managing

performance

4


Use of Patient Experience Tracker

enables patients to provide real time

data, some of which is then used to

inform board reporting

DoN on-going

Use of national Net Promoter Score

reported to Board monthlyDoN from May 2012

Patient Story at board for first time. Chair Aug-12

Quality Walks - currently involving CE

and Chair, to be extended to involve

NEDs

DoNJuly onwards

Sept onwards

Verbal update at board meetings during

finance report (CIPs) regarding Quality

Impact assessments and those items

that have been rejected on the grounds

of quality.

DoNFrom June

onwards

Post implementation review of QIA's for

CIPs, with evidence of mitigating actions

in place

DoN / CEO /

PMO

01/08/2012 will

be evidence at

board for first time

in October 2012

SI reports, complaints information,

nursing indicators, PROMS, CQC

updates, all continue to be presented at

board on regular basis, as indicated on

the board calendar

DoN / Chair On-going

Committee structures are constantly

reviewed, with annual self evaluation on

high level committees - CAC, etc

DoN On-going

Board committee structure is constantly

reviewed, with annual self evaluation on

high level committees - Audit, QAC

Chair / Sec On-going

3

Trust complies with

Monitor's Quality

Governance

Framework in all

aspects









alongside.

Appropriate quality information is

being analysed and challenged

Board is assured of the robustness

of the quality information

Board actively engages patients,

staff and other key stakeholders on

quality

5


Clinical audit programme driven by

national audits and risk assessment, and

results published annually in Quality

Account

DoN end June 2012

New additional clinical audit function

being set up: spec to be approved by

Board for external tendering process.

CE May-12

External clinical audit tender to be agreed

and programme implemented

CEO / MD /

DONJan-13

4Assurance (RSM Tenon electronic

system) to be used to generate reliable

reports for future board review.

DoN Jan-13

recruitment of data quality manager with

responsibility for fixing incorrect data from

DQ team to business units

DO completed

Data quality audit review to be

undertaken.DO Sep-12

Information in 1/4ly and annual quality

reports being displayed clearly and

consistently

DoN on-going

Information to be humanised where

possible (e.g. unexpected deaths shown

as absolute number rather than

embedded in a mortality rate)

execs June onwards

Continue use of 'round-up' on staff

intranet to increase staff awareness of

'new' measures / guidance / policies

DoN on-going

Governance process (stering group) to

be established to monitor the quality

workstream work (including exec

sponsors)

DoN Aug-12

Core Brief meetings have a 'Quality'

agenda item for topical issues as they

arise

DoN on-going

3

Trust complies with

Monitor's Quality

Governance

Framework in all

aspects









alongside. Quality information is being used

effectively.

Board is assured of the robustness

of the quality information

Board promotes a quality

focussed culture throughout the

Trust

6


Presentation of BU performance

management framework to board

Board can articulate how BUs are

held to account and able to identify

actions taken to address areas of

under performance.

DO May-12

DO Sep-12

DoN Sep-12

Performance Management

Framework for Business Units in

place

Review of governance arrangements in

the BUs to ensure new performance

management processes are understood

and being adhered to, including:

review of quality governance framework

in specific areas including QAC

Board assurance

and holding to

account

4

Clear performance management

process in place, with emphasis on

Business Unit structure.

7


BMs to be comfortable with the

differences between the corporate

risk register and the BAF.

Chair / CE 06/06/2012

Clear processes and

responsibilities in place relating to

the Board's involvement with the

BAF and Corporate Risk Register.

Chair / CE 06/06/2012

Board development session was held in

June - further action arising - set up

assurance framework meetings with

RSM Tenon to carry out more work on

the BAF, its workings, its content and

overall 'fit' in the Trust's risk management

structure

BMs comfortable with the

differences between the corporate

risk register and BAF Clear

processes and responsibilities in

place relating to the Board's

involvement with the BAF and

Corporate Risk Register.

Chair / CEend commence

Sept

Audit Committee and Quality Assurance

Committee ToR's to be reviewed to

ensure they align with new risk

management strategy responsibilities

relating to corporate risk register and

BAF.

Internal Audit annual report

2012/13 reports no weaknesses

arising from the process of controls

concerning the BAF.

Secend commence

Sept

Risk appetite - see also objective 2

above.

BMs will have common view on

risk parameters the board is willing

to accept

Chair / CE end August

Board development session on the

personal and corporate liabilities of

directors (facilitated by Marsh)

BMs to be fully cognisant of the

liabilities and risks that their

appointment may pose both for the

board as a whole, and as

Chair 06/06/2012

Appropriate risk

management

processes, systems

and culture are

embedded within

the organisation as

a whole (strategic

risk included here,

organisational risk

dealt with in separate

SMART objectives)

RSM Tenon Review (Sept 2012)

reports that risk management

systems have been fully

implemented with heightened

awareness of the management

structures put in place.

Further board development session for

BMs to address any residual concerns

regarding the operation of the BAF

(facilitated by RSM Tenon)

5

8


RSM Tenon to undertake review of board

finance reports

Finance reports to be consistent

with best practiceFD completed

Board workshop to review best practice

from elsewhere across a range of board

reports, clarifying improvements that will

be made and what BMs want to see. To

include development of a 'house style'

report where appropriate.

Board reports in general will reflect

best practice in line with other FTs.

Continue to develop 'house style'

reports and covers for consistency

of reporting

Chair end Aug

Continue to develop board reports to

clearly articulate key risks and to increase

the use of benchmarking, triangulation

and trend analysis.

To include reviewing and developing the

integrated performance report.

Format of all board reports is

amended where required to ensure

that they articulate the key risks

and draw the board's attention to

areas of focus - report cover

sheets to link to BAF

Execs on-going

Continue to develop the integrated

performance report.

Performance failures can be

forecast by use of trending

analysis.

Execs on-going

Ensure BMs are aware of data quality

testing and are cognisant of this when

reviewing performance

EDs can demonstrate tangible

actions taken to improve the layout

and content of their board reports

DO May-12

Review process in place to ensure the

board have reviewed and approve all key

submissions to Monitor.

All board approved submissions to

Monitor appear on the board

agenda and minutes reflect

approval before submission.

CEcomplete and on-

going

Deloitte Board Governance

Assurance Review in

September 2012 will report

improved clarity and consistency

of board reports

6

Improve board

reporting and

content of board

reports

9


Board development session to discuss:

- effective challenge;

- assurance v reassurance;

- operational v strategic

(link to board development session in

objective 1)

Chairby end Aug

5th September

Induction programmes for new Directors

should be reviewed to ensure that board

members - particularly those who have

not previously held board positions -

understand their role in board

engagement and challenge

Chair by end October

BMs should undertake individual

coaching to address feedback provided

as part of the Deloitte review

BMs on-going

Exec board reports (written and verbal)

should ensure that they clearly direct

NEDs to the areas of greatest risk

Execs feel held to account. CE on-going

7

Improve board

engagement and

the quality of

challenge

BMs to have a clear understanding

of how these attributes help to

focus a board to become more

effective


Assurance Review in


improved board engagement

and quality of challenge from all

board members

10


Increase the use of the board calendar to

ensure sufficient time is given to debate

and analysis of key risks and implications

in advance of key decisions. (SEPS)

Sec

01/05/2012

(pending formal

SHA decision)

SEPS should come to the board as a

formal 'go / no go' decision supported by

full options appraisal and risk analysis.

Chair

01/06/2012

(pending formal

SHA decision)

Agendas do not show "to follow"

items and papers subsequently

received late by BMs

Chair / CE on-going

Board papers / agendas show

correct action sought from board

i.e. approval, discussion, etc.

Chair / CE on-going

Review content, style and length of board

minutes

Board minutes should be more

succinct, consistent style Sec / Chair complete

Actions to be summarised at the end of

each agenda item, actions placed on

board action tracker with timescales and

owners.

Actions clearly evidenced, easy to

follow, and reasoning given when

timescales are not met or extended

Sec / Chaircomplete and on-

going

More effective use

of board agenda

and forward plan

for decision making

Board agendas reflect the

content of the board calendar

with infrequent items appearing

that are unplanned.

BMs are confident that there are

no outstanding issues before

making well informed, risk

assessed decisions

8 Board reports submitted by designated

deadlines

11


PAS procurement business case to be

submitted to board

PAS system replaced well in

advance of April 2014, when

current system ceases to be

supported.

MD May board

Data quality report to be presented to the

Board

Board is fully aware of the issues

relating to data quality and are

made aware of plan of action to

improve data quality throughout

organisation.

DO May board

Improve data

quality 9

Included as part of 'organisational' SMART objectives

12


Approve Terms of Reference for the

BoardChair complete (March)

Directors' Register of Interests updated Sec complete (March)

Matters reserved for the board' updated

and approved by the BoardChair complete (April)

Split roles of Chair and CE approved by

the BoardChair complete (April)

Code of Conduct for Directors approved

by the BoardChair May board

SFI's and Scheme of Delegation to be

reviewed by the Audit Committee before

submission to board

FD end Sept

Standing Orders to be updated and

approved by the BoardChair

calendared for

November

Review of board sub-committee

structure, including:

- appropriateness of structure, and

ensuring roles and remits are clear;

-ToR's remain current and in-line with

best practice;

- membership of committees is

appropriate;

-improved reporting of sub-committee at

Board.

Chair on-going

Update and approval (in conjunction with

the Governors) of ConstitutionChair end Sept Oct

Board Governance

Structure

Corporate documentation

required by statute, regulation or

in line with best practice, is in

place

Appropriate and up to date

documentation guides the Board in

understanding its role, the

parameters of its authority and

mitigates the risk of financial and

reputational loss, regulatory breach

and personal liabilities for BMs

10

13


Workshop aimed at developing the Board

as a team (exploring personality

preferences, the skills and experiences of

individual board members, and agreeing

behaviours not covered by the Code of

Conduct.)

Chair on-going

Set up 'time out sessions' for whole board

to seek to build relationships in an

informal environment

Chair on-going

Explore Board

dynamics11


Assurance Review in


better interaction between board

members

Clearer understanding amongst

BMs of the styles and strengths of

Board colleagues

14


Impact of the Board to Ward programme

should be kept under review

(see also objective 3)

The Board can point to

improvements made as a result of

the 'Board to Ward' programme

DoN July onwards

Board to agree a structured programme

of events to increase the profile of the

Board with staff, patients and key

stakeholders, including:

- Schedule of monthly visits by BMs to

outlying clinics / sites to allow

engagement with staff / patients away

from main site

-

Staff and patients will be able to

recognise BMs and to articulate

their role and appreciate the

impact of the work of the Board

CE

on-going - from

August, included in

CE / Chair verbal

report

Promote board meetings and agendas

more widely

Wider range of stakeholders feel

'welcome' to attend board

meetings and are able to

understand Trust strategy and

direction

Chair / Sec.

/ CommsJune onwards

12Visibility of the

Board

Increased instances of board

visibility and engagement with

staff, patients and key

stakeholders

15

This document should not be read in isolation; several objectives cited in this document are linked to

those that are detailed in the separate 'organisational' objectives already agreed by the Board. For

example, objective 5 herein relating to risk management is aimed more at the management of

strategic risk and how risk relates specifically to the Board, as opposed to the roll out of risk

management processes throughout the organisation, which is dealt with separately.

It should also be noted that although dates are provided herein for accomplishment of projects, this

does not mean that the matter is thereafter 'lost' from sight of the Board. On-going monitoring,

improvement, review and updating will continue to take place where appropriate. For example,

objective 2 refers to the approval of certain strategies - once approved, the strategies will continue to

be monitored and reviewed at appropriate intervals, thus reflecting the dynamic nature of the Board's

vision and role.

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GOVERNANCE SMART objectives / SUHFT board development ... · GOVERNANCE SMART objectives / SUHFT board development programme Specific objective Measurable Success Actions required

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