Governance

Marti Lӧtter Group Head of Governance

UL Hospitals October 2019

Vision

A health service meeting the National Standards for Safer

Better Healthcare provides care that is safe, effective, person-centred and that promotes better health and well being of the people using it.

To achieve this the service has good leadership, clear accountability, effective management and a well-organised, skilled and competent workforce.

It uses high quality information and its available resources

effectively and efficiently to deliver high quality, safe, reliable healthcare for its service users.

‘Everyone in healthcare has two jobs when they come to work everyday: to do their work and to improve it’

“We are all responsible and together we are creating a safer healthcare system

Quality improvement is everybody's responsibility”

Source: Batalden, professor of paediatrics and a senior fellow of the Institute of Healthcare Improvement

Governance for Quality and Safety

What is it…..?

• It is described as: • the system through which healthcare teams are

accountable for the quality, safety and experience of service users in the care they have delivered.

• For health care staff this means: • Specifying the clinical standards you are going to

deliver and showing everyone the measurements you have made to demonstrate that you have done what you set out to do.

This can be achieved by creating an environment in which there is

transparency of responsibility and accountability for maintaining

standards through measuring against set targets to ensure excellence in

patient care (HSE, 2018).

Governance

Key Components of Governance

Knowledge and skills: Management teams have the knowledge and skills to achieve their role in driving quality care

Leadership and Accountability: Management team are clear about leadership and accountability

Information: Intelligent use of information to measure, monitor and oversee quality and safety of care

Culture: A culture of learning focused on quality of care

Relationships: The organisation promotes strong relationships that partner with patients and staff to facilitate the alignment of the entire organisation around the quality of care

Quality Improvement: There is a quality improvement plan in place for identified risks aligned with national and organisational priorities

Key Components of Governance

Critical success factors for Clinical Governance

• Responsibility and accountability

• Risk management strategy with clear policies

• Programme of quality improvement activities

• Clear policies and procedures to identify and correct poor

performance

UL Hospitals Group Governance Structure

Minister for Health

DG HSE

National Director Acute Hospitals

CEO

ULHG Board of Directors

CFO

CAO

COO

DOM

DOHR

CDONM

CIO

CCD

Group Head of

Quality

Group Head of

Communications

Group Head of Governance

Departments

Diagnostics

Clinical DirectorAssociate CD

DGMBusiness Manager

Pathology ManagerRSM

Chief PharmacistAHP Manager

Radiology

Pharmacy

H&SCPSLTOT

PodiatryPhysiotherapy

DieteticsMSW

Pathology

Biochemistry

Blood

Transfusion

Serology/

Immunology

Microbiology

Haematology

Histopathology/

Mortuary

MedicineClinical DirectorAssociate CD x 4

DGM x 2DON

BM x 3

Perioperative

Clinical DirectorAssociate CD x2

DGM (H&S)DON

Business Manager

M&CHClinical Director

Associate CD DGMDOM

Business Manager

Operational

ServicesDGM

Facilities Manager Clinical Eng

ManagerMaintenance

Manager

ODONOperational

ADONS Operational DON Ennis

Operational DON Nenagh

Scheduled

CareDGM

Unschedueled Care DGM

QualityGroup Head

of Quality G8

Quality & Safety

Managers PALS

G7 x 7

Informatics Planning and Performance

eHealth Division

PPBI HIPE ICT

HR

GM X 1G8 x 1

FinanceGM x 2 G8 x 5

DivisionsGeneral

AnaestheticsPain Medicine

VascularOrthopaedicsMaxillofacialCritical Care

General SurgeryENT

UrologyOpthamology

ObstetricsNeonatologyGynaecologyPaediatrics

Clinical Engineering

MaintenanceCatering

HCA Portering

Contract Services

Divisions

Emergency Med.

Acute Medicine

Elderly Medicine

Renal

Neurology

Infectious Diseases

Cardiology

Respiratory

Endocrinology

Rheumatology

Gasteroeneterology

Dermatology

Oncology

Clin Haemotology

Palliative Care

___________________________Colette Cowan CEO ULHG

___________________________Noreen Spillane COO ULHG

ACD Quality

ULHG Organisational Governance Structure V12 21/05/2018

CSBUACD x 1

Data Manager G70.5 x ADON

Directorates

Group Head of

Strategy

PMO Lead

NDTP Training Lead

UL Hospitals Group Executive Management Team

CEO Ms Colette Cowan

UL Hospital Group Board

A/Chief Financial Officer

Mr John Cowhey

Chief Clinical Director

Dr G Burke

Clinical Directors Dr Denis O’Keeffe - Diagnostics Dr Catherine Peters– Medicine Mr D Waldron– Peri-Operative Dr Siobhan Gallagher– Maternal & Child Health

Chief Academic

Officer

Prof Paul

Burke

Chief Operations

Officer

Ms Noreen Spillane

Chief Director of

Nursing &

Midwifery Ms Margaret

Gleeson

Interim HR Director

Lorraine Rafter

Director of Informatics, Planning and Performance

Vacant

Director of Comms

Ms Elaine Connolly

Head of Strategy/ Head of

Governance

Suzanne Dunne Marti Lӧtter

Governance of UL Hospitals Group

Exte

rnal

Ex

ecu

tive

D

irec

tora

tes

Directorate Team Members: Clinical Director

Directorate Manager Directorate Nurse Managers/Service Managers

Business Manager QPS Manager Accountant HR Liaison

HSCPs

Service Managers

Senior Grade Staff

Basic Grade Staff

Nursing

ADON

CNM2

CNM1

Staff Nurse

MTA/Porter

CNM3

CNS

ANP

DON

CDON Consultants

NCHDs

Registrars Clinical Specialists

CD

CEO

CCD

Consultants

Different Levels of Shared Clinical Accountability according to level of responsibility within the Governance Structure

ACD

Admin staff

GM

Grade 5

Grade 4

Grade 3

Grade 6

Grade 7

Grade 8

MTA

Catering

Maintenance

Engineering

Operational Support Services

Porter

Head of Governance Role

GOVERNANCE We work with departments and leaders of, developing and emerging states to

enhance their effectiveness. Brief: To provide Governance through Measurement against a baseline. To Achieve: Quality Assurance (clinical and non-clinical quality data) that cascades from one level to the next to prove continuous quality improvement Organograms of reporting relationships Function of each grade and post List of duties and responsibilities for each grade Service Analysis – KPI selection for Balanced Score Cards Risk Registers Quality Improvement Plans Project Trackers Audit Forward Plans

Integrated Corporate and Clinical Governance

“The main lesson I take from the problems at Midstaffs is that in future, we

must never separate quality and financial data. They are always two sides of

the same coin.” (Secretary of State for Health, England, 2010) “….corporate

and clinical governance arrangements must include unambiguous lines of

accountability for assuring, performance managing and improving the quality

and safety of services at a national, regional, local and clinical level” (Minister

for Health, 2013)

• 1. The HIQA National Standards for Safer Better Health Care (2012) 2. HSE Code of Governance of which The Performance and Accountability Framework of the HSE (2017) form an integral part. 3. The 10 facets of Clinical Governance, Jaggs-Fowler (2011) 4. The Quality Risk Management System (QRMS) of the HSE(2008) with Pearson's Law as guiding principle.

“That which is measured improves. That which is measured and reported improves exponentially. “

- Pearson's Law-

UHLG Governance Model underpinned by

CEO’s Priorities 2019

Priority Action Sponsor Owner Completion Date

Strategic Priority 1 –

Clinical Transformation

1. Implementation of Sláintecare. Implementation Strategy & Action

Plan.

CEO CEO/ Executive Team Q 1-4

2. Implement targets for Clinical Transformation to include Medical

Transformation.

CEO CCD Q 4

3. Plan & Co-Design place based Integrated Care Models. CEO CEO/ Executive Team Q 1-4 Strategic Priority 2 –

Digital Health

4. Progress on Microsoft Projects & identify other early innovations

in eHealth.

CEO CIO Q 3

5. Establish accessible Data Analytics & Clinical Information for

Clinical Groups.

CEO CIO/CCD Q 2

6. Implement Clinical Information Systems including expansion of

Maxims.

CEO CIO/COO/ CCD Q 4

7. Enable Paperless Systems to support Patient Care & operational

effectiveness.

CEO CIO/COO/ CCD/ CDONM Q 3

Strategic Priority 3 –

Research & Innovation

8. Progress Plans for Joint Health/University Health Science

Academy.

CEO Head of Strategy/

CAO/CCD/ CDONM

Q 3

9. Continue Progress with Future Innovations in Robotics,

Technology & Integrated Care

CEO COO/ CDONM/

CAO/CCD/ CIO

Q 2-4

10. Establish Formal Approach for Integrated Care & Age Related

Disease

CEO CEO/ Executive Team Q 2-4

Strategic Priority 4 –

Collaboration & Alliance

Value of New System of Assurance of HSE

& Board Advices

CEO set priorities according to National Goals

CCD/COO/CDONM/CIO/CFO/DHR priorities and QIP’s to align

with CEO priorities

Each Directorate must provide data on the 4 elements that

enables the delivery of an excellent heath service:

Quality, Finance , Access, Resources

Each Directorate account and are responsible on a monthly basis

at Performance Meetings using the Balanced Scorecard Model

Balanced Scorecard

The balanced scorecard is a strategic planning and

management system that is used extensively in business and

industry worldwide to align business activities to the vision

and strategy of the organization, improve internal and external

communications, and monitor organization performance

against strategic goals (Norton and Kaplan,1992)

EXTERNAL HIQA (2012)

Capacity and capability

Dimensions of Quality

Process

Outcome

Structure

4 Dimensions of Balanced Scorecard

Patient and Service User

Quality and Safety

National Balanced Scorecard for Acute Hospitals

EXAMPLE

Levels of Scorecards

National

UHL Board

CEO

Executive

Directorate

Departmental

CEO /Executive Forum 2

COO/CDONM/CCD/CFO/HR/CIO/DOM

GM/CD/ACD Forum 3

Directorate Team Meetings

Forum 4 Departmental

Meetings

Forum 5 Frontline

Data Cascades Form One Level to the Next

CEO /UHL BOARD Forum 1

COO/CDONM/CCD/CFO/HR/CIO/DOM

Theme 5 Leadership, Governance and Management NSSBH (Departmental Level)

Standard 5.1 Clear Accountability Do you know where to access your departmental organogram with reporting relationships? (organogram) Do you know what every team member’s responsibility is in your department? Standard 5.2 Strong Governance Do you know where and how to access departmental policies? Have you read and signed them? What happens if these policies are breached? Standard 5.3 Statement of purpose Do you know where to access your department’s statement of purpose? Standard 5.4. Effective Strategic Planning Do you know the strategic goals for your department/area? (strategic or development plan) Do you know where to access this document? Standard 5.5 Effective Operation Planning Do you know the operational plan for your department/area? (operational plan) Are you clear on the day-to day running of the department in times of crisis? Do you know where to access escalation or prioritisation documents for your service? Standard 5.6 Promoting a Culture of Quality and Safety Do you have monthly staff meetings where you can voice any concerns you might have? (minutes) Do you reflect as a department on complaints/compliments and incidents ? Logs on Q-Pulse Do you receive learning notices via e-mail?

Theme 5 Leadership, Governance and Management NSSBH (Departmental Level)

Standard 5.7 Supporting Staff in delivering Quality and Safety Do you know how and to whom to report an incident? Do you know what to do when a patient complains about the service? Do you know what to do if you witness an error in patient care? Are training for staff in incident management and QIP provided? (training Records) Standard 5.8 Monitoring arrangements for quality and safety Do you audit your service regularly and develop and implement quality improvement plans as a result. Do you routinely collect data ? (balanced Scorecards) Do you maintain a risk register for your department? (Risk register) Standard 5.9 Service Agreements Can you access applicable documents in relation to SLA’s What are the monitoring arrangements in terms of quality assurance for 3rd party providers?(SLA’s) Standard 5.10 Compliance with Legislation Are you aware of any legislation governing your service? Do you know where to access this? Standard 5.11 Implementation of Standards, Alerts, Guidance and Recommendations Are all HIQA recommendations from previous reviews implemented in your service area? Is all relevant standards alerts guidance and recommendations produced by relevant regulatory bodies applied in your service.

THANK YOU