The National Quality Board 2011 describe the board’s responsibilities for quality as being threefold:
- to ensure that the essential standards of quality and safety (as determined by CQC’s registration requirements) are at a minimum being met
- to ensure that the organisation is striving for continuous quality improvement and outcomes; and
- to ensure that every member of staff that has contact with patients, or whose actions directly impact on patient care, is motivated and enabled to deliver effective, safe and person‐centred care
It is therefore the responsibility of the board to create a culture within the organisation that enables clinicians and clinical teams to work at their best, and to have in place arrangements for measuring and monitoring quality and for escalating issues, including, where needed, to the board. They should encourage a culture where services are improved by learning from mistakes, and staff and patients are encouraged to identify areas for improvement, and not be afraid to speak out.
(Quality Governance in the NHS, DOH, 2011)
The Inmind Healthcare Corporate Quality Governance structures and processes provide assurance to those who use services that we ensure the service delivery contributes positively to the experience of patients, service users and the staff who work within our services.
The structures and processes that are in place to monitor and improve the organisations quality performance includes:
- Making sure that required standards are achieved and ultimately exceeded
- Where shortfalls are evident, action follows to improve performance
- Setting out quality improvement plans that meet and exceed customer expectations
- The improvement in the quality of clinical activities and care interventions.
- Identification of best practice and sharing learning opportunities
- Being clear about the risk factors that impact on the delivery of quality care and taking steps to reduce and eliminate them
Organisational learning is essential to providing future safe service delivery. Inmind has a defined and systematic approach to the investigating and learning from incidents and analysis of events. This enhances the development of risk assessment and management frameworks within individual services and the corporate structure. A culture of openness and learning is fostered and encouraged and underpins transparent and open working practices.
It is important that all staff are actively engaged in continually improving the quality of care for service users. The effective implementation of quality governance is best achieved if staff at all levels within the organisation are involved, encouraged and supported to participate in activities to improve care delivery.
In order to engage all staff the following is required:
- Strong leadership to ensure understanding of the aims and purpose of quality governance
- Corporate and Hospital level quality governance committees
- Well communicated Corporate and Hospital level quality governance structures
- Proportionate responses to incidents
- A culture of no blame but personal accountability
- The organisation learns from experience
- Recognition for good practice
- A culture that encourages and supports learning and development
- Clear systems and processes for quality governance and clinical audit
- Robust and timely information on quality governance activities.
In order to provide the Chief Executive and Board with assurance around quality governance, a Corporate Quality Governance Committee will meet on a quarterly basis and its membership includes:
- Chief Executive Officer
- Group Operations & Governance and Compliance Director
- Hospital Directors / Registered Managers
- Unit clinicians (as appropriate to agenda items)
- Service user representative (as appropriate to agenda items).
The Corporate Quality Governance Committee will monitor the implementation of governance across the organisation. It will ensure that appropriate systems are in place to support the process and structures, as well as keep this under review.
Below is an organogram that illustrates the Quality Governance structure across Inmind Group.
Chief Executive & Company Directors
Director of Nursing & Operations
Safety & Risk
Serious Incidents (SIRIS)
Incidents (IR1) Self Harm & Suicide
Clinical Risk Management
MAPA, Restraint & Seclusion
Clinical & Cost Effectiveness
Health Promotion & Improvement
Clinical & Commissioner Audit
CQUIN & Quality Improvement Plan
CPA & Care Planning
Clinical & Service Development
Information & People Development
Statutory & Mandatory Training
Appraisal & PDP
Staff Recruitment & Retention
Policy Development & Review
Patient Involvement & Experience
Ward & Hospital Service User Group
Mental Health Act Compliance & MCA
Patient Complaints and Compliments
Carer & Visitor Needs
Accessible & Responsive Care
Patient Survey & Action Plan
Carers Survey & Action Plan
Commissioner/Customer Survey & Action Plan
Catering Survey & Action Plan
Care Environment & Amenities
Clinical Audit Group
Preventative Maintenance Programme
Clinical Audit Group
Hospitals & Services
Battersea Bridge House
Southleigh Community Hospital
Woodleigh Community Hospital
Sturdee Community Hospital
Purley View Nursing Home