1. Authority
1.1 The Quality Committee is constituted as a standing committee of the Board of Directors and has no executive powers, other than those specifically delegated in these terms of reference. Its constitution and terms of reference are set out below and can only be amended with the approval of the Board of Directors.
1.2 The Committee is directly accountable to the Board of Directors and is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee or contractor of the Trust and all employees and contractors are directed to cooperate with any request made by the Committee.
1.3 The Committee is authorised by the Board of Directors to secure the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary for or expedient to the exercise of its functions.
2. Purpose
2.1 The Quality Committee will provide assurance to the Board of Directors on the quality of care provided to the Trust’s patients, specifically in relation to patient safety, clinical effectiveness and patient experience. It will do so by:
- Ensuring that the Trust has appropriate quality governance structures, systems, processes and controls in place to achieve consistently high quality care and to meet the Trust’s legal and regulatory obligations.
- Reviewing progress against the Trust’s quality priorities and quality improvement plans as set out in the Quality Plan and Quality Account.
- Seeking assurance that key risks relating to quality of care, as included on the Board Assurance Framework and the Corporate Risk Register, are being effectively managed and mitigated.
- Identifying and reviewing themes and trends in key quality indicators, seeking assurance that appropriate action is being taken to respond to and learn from these.
- Seeking assurance that appropriate progress is being made in implementing action plans put in place to address any shortcomings in quality of care.
2.2 The role of reviewing the quality performance indicators within the Integrated Performance Report on a monthly basis will primarily be undertaken by the Performance Committee, which is a standing committee of the Board of Directors. The Performance Committee and the Board of Directors may remit more detailed review of any indicators of particular concern to the Quality Committee. The Quality Committee may advise the Performance Committee on any specific quality indicators requiring ongoing oversight.
2.3 The Trust’s Audit Committee will retain overall responsibility for monitoring, reviewing and reporting to the Board of Directors on all aspects of governance, risk management and internal control. It will do so having regard to the assurance provided by the Quality Committee in undertaking its work programme.
3. Membership
3.1 The members of the Quality Committee shall be appointed by the Board of Directors and comprise:
- Three Non-Executive Directors
- Chief Nurse
- Medical Director
3.2 One Non-Executive Director will be appointed as the Chair of the Quality Committee by the Board of Directors. One Non-Executive Director member of the Quality Committee should preferably have clinical experience or qualifications. At least one of the Non-Executive Director members should also be a member of the Audit Committee and at least one should also be a member of the Performance Committee.
3.3 The Chief Executive will identify an Executive lead for the Committee.
3.4 A quorum shall be three members, comprising two Non-Executive Directors and one Executive Director. In exceptional circumstances, an Executive Director member may send an appropriate nominated deputy in their place and this will count towards the quorum.
3.5 Members should make every effort to attend all meetings of the Committee and will be required to provide an explanation to the Chair of the Committee if they fail to attend more than two meetings in a financial year. If a member fails to attend more than three meetings in a financial year, the Chair of the Committee will consider with the Chair of the Trust the appropriate action to be taken. The Committee Secretary will monitor attendance by members and report this to the Chair of the Committee on a regular basis.
4. Attendance and secretariat
4.1 The Director of Clinical Quality will attend all meetings. Other Executive Directors and other Trust staff will be invited to attend for specific agenda items with the agreement of the Chair of the Committee.
4.2 The Council of Governors may nominate up to two governors to attend each meeting of the Committee to observe proceedings. The observation of Board assurance committees by governors shall be subject to conditions agreed by the Board of Directors. The Chair of the Committee may in exceptional circumstances exclude governors from being present for specific items.
4.3 The Director of Corporate Affairs will ensure that the Trust Secretariat provides a Secretary to the Committee and appropriate administrative support to the Chair and committee members. This will include agreement of the agenda with the Chair and Executive leads, collation and circulation of papers, producing the minutes of the meetings, keeping a record of agreed actions and follow up, and advising the Chair and members of the Committee as appropriate.
5. Frequency of meetings
5.1 Meetings will be held six times a year, generally at a frequency of every two months.
5.2 The Chair may convene additional meetings of the Committee if necessary to consider business that requires urgent attention.
6. Reporting
6.1 The Quality Committee will receive a regular report from the Executive lead covering issues for escalation. The Committee will also receive regular exception reports from any sub-committee it establishes.
6.2 The minutes of the Quality Committee’s meetings will be circulated for information to all members of the Board of Directors. An exception report will be presented to the next meeting of the Board of Directors following each Committee meeting to draw attention to any matters that require disclosure or escalation to the Board, specifically where there is a lack of assurance in any aspect of quality of care.
6.3 The Quality Committee will provide an annual report to the Board of Directors on the effectiveness of its work and findings, including its review of relevant Board Assurance Framework entries and regulatory compliance. This will be based on an annual effectiveness review to be undertaken by the Committee which will inform its forward work plan.
7. Review
7.1 The terms of reference will be reviewed by the Committee and approved by the Board of Directors at least every two years.
8. Specific duties
8.1 Receive a report at each meeting covering issues escalated by the Executive lead, including specific sections on patient safety, clinical effectiveness and patient experience.
8.2 Receive a report at each meeting covering Maternity and Perinatal Care, including regulatory and compliance updates.
8.3 Review the structures, systems, processes and controls in place in relation to patient safety within the Trust, with a particular focus on the key patient safety objectives as set out in the Trust’s Quality Plan and Quality Account. This will include a specific patient safety report to each meeting focusing on key themes and trends, learning and improvement.
8.4 Review the structures, systems, processes and controls in place in relation to clinical effectiveness and patient outcomes within the Trust, with a particular focus on the key clinical effectiveness objectives as set out in the Trust’s Quality Plan and Quality Account.
8.5 Review the structures, systems, processes and controls in place in relation to patient experience and engagement within the Trust, with a particular focus on the key patient experience objectives as set out in the Trust’s Quality Plan and Quality Account. This will include a twice yearly patient experience report focusing on key themes and trends, learning and improvement.
8.6 Receive and review those entries on the Board Assurance Framework (BAF) and the Corporate Risk Register (CRR) which are to be overseen by the Quality Committee and ensure that they are appropriately reflected on the Committee’s work programme to enable the Committee to gain assurance on the effectiveness of the controls in place and progress in addressing gaps in control and assurance. Identify through escalation reporting to the Board of Directors
8.7 Receive a twice yearly report on the structures, systems, processes and controls in place in relation to health and safety compliance in the Trust.
8.8 Seek assurance on the effectiveness of the systems and processes in place to assess the quality impact of Cost Improvement Plans and other significant service changes.
8.9 Receive and review the following annual reports and plans on behalf of the Board of Directors:
- Infection Prevention and Control (plus six-monthly update)
- Safeguarding Children and Vulnerable Adults (plus six-monthly update)
- Patient Experience report
- Medicines Optimisation
- End of Life Care
- Clinical Audit report (plus six-monthly update)
- External Review report
8.10 Review the proposed Internal Audit Annual Plan and make recommendations to the Audit Committee on the Internal Audit work programme as relevant to the remit of the Quality Committee.
8.11 Review the findings of Internal and External Audit reports covering matters within the remit of the Quality Committee, seeking assurance that appropriate actions are identified and implemented in response to recommendations and that learning is shared across the organisation.
8.12 Review the development of the annual Quality Account, including the annual quality objectives, ahead of submission to the Board of Directors.
8.13 Receive and review reports on significant concerns or adverse findings highlighted by regulators, peer review exercises, surveys and other external bodies in relation to areas under the remit of the Committee, seeking assurance that appropriate action is being taken to address these.
8.14 Review any quality issues referred to the Committee by the Board of Directors, the Performance Committee or the Workforce and Education Committee.
8.15 Develop an annual work programme agreed by the Committee to discharge the duties as set out above.
8.16 Undertake an annual review of the effectiveness of the Committee to inform the Committee’s annual report to the Board of Directors and the following year’s work programme.
8.17 Undertake any other responsibilities as delegated by the Board of Directors.
Date approved
18 January 2023
Approved by
Board of Directors
Next review date
January 2025