Slide 1

Report
Good Governance
Dr John Bullivant
Visiting Senior Fellow in Governance
University of Glamorgan
Professor Michael Deighan
Special Advisor on Governance to
NHS CGST, Bentley Jennison & DH Commercial Directorate
Joint Authors of the
Integrated Governance Handbook
1
Format
• Good Governance- emerging themes in health in UK
with emphasis on systems, behaviours & relationships
• Integrated Governance 10 key issues- how are we doing
• The expanded role of the audit committee & SUI audits
• Commissioning and Regulation Issues
• Stepping up to whole system governance
• What needs to be done?
• What systems, behaviours or relationships need to
change?
2
Focus
Effective Boards are critical to the success of
organisations in the public and private sectors.
They set the strategic tone for an organisation,
providing leadership and a clear focus on
priorities. As forums of challenging debate,
Boards are unified by a clear sense of collective
responsibility. Effective Boards are innovative
and flexible, but maintain a resolute focus on
risks, accountability and performance.’
(Lynton Barker, Public Services Productivity Panel, 2004
3
Integrated Governance
Handbook
‘the "platform" on which local NHS organisations should build
improved accountability, strategy and leadership systems”.
It lays out a programme of reforming local governance
arrangements with the aim of better decision making, leaner
committee structures, achieving a stepped change in
accountability arrangements and ensuring that governance
systems deliver value for money.
This document aims to ensure that the governance
arrangements for the Trust match this template of good
practice.’
Richard Douglas, Finance Director of the NHS ,
quoted in The Scheme of Governance for
West Hertfordshire Hospitals NHS Trust
4
Integrated Governance
Boards are now encouraged to move away
from silo governance and develop
integrated governance that will lead to
good governance…..
and to ensure that decision-making is
informed by intelligent information
covering the full range of corporate,
financial, clinical, information and
research governance.
SHA Standing Orders and Standing Financial Instructions Sect 1.4,
5
September 2006
Foundation Trusts
Financial planning and strong governance
remain essential to foundation trusts’
success, says Monitor.
• Between 1 April 2004 and 1 March 2007, 26
NHS trusts’ application for foundation trust
status were deferred; postponed or rejected.
The reasons for this are set out below:
• Finance
78%
• Governance
22%
Financial reporting opinion
Board capability
Clinical governance
Systems and control
–
10%
6%
3%
3%
Monitor: 1.3.2007
6
Integrated Governance
Systems processes and behaviours
by which trusts lead, direct and
control their functions in order to
achieve organisational objectives,
safety and quality of services and in
which they relate to patients and
carers, the wider community and
partner organisations.
7
Wales
Population: 3 million
Health Organisations: National Assembly for Wales
Health & Social Care Dept, Regional Offices (3),
Local Health Boards (22), Combined acute and
community, one ambulance service
Accountability: Governance to Minister, performance
to Director through Regional Offices (3)
Regulation: WAO, HIW, Healthcare Commission
Governance: Boards of Trusts, Boards of LHBs, Clinical
Governance, CHCs, Partnerships
Improvement: Designed for Life, NLIAH, Performance
Unit, Wanless, Beecham
Changes: , Government of Wales Act, Central
Commissioning, Consortia, Mergers?, Reviews,
Election?
8
Wales
9
Underlying Principles
Some big issues eg finance
Strategy & assurance against
strategic risks
Central direction and targets, local
context
Patient focus & safety
Use of resources & delivery
10
Simple Rules
Focus on:
Purpose & Strategy
Unified processes, scrutiny and
reporting for (clinical and non
clinical) activity, performance and
resources
Behaviours
11
The Background
12
Key References
2003 Governing the NHS, Appointments Commission
2004 Integrated Governance debate paper, NHS Confederation
2004 Integrated Governance Board Assurance Prompts, NHS CGST
2005 Audit Committee Handbook, DH/HFMA (Gateway 5706)
2006 Integrated Governance – a handbook for executives
and non-executives in healthcare organisations, Dept
of Health (Gateway 5947)
2006 The Intelligent Board, William Wells/Appointments Commission
2006 NHS Foundation Trusts Code of Governance, Monitor
13
Standards for Better Health
Integrated Governance is explicitly
identified under governance domain D3:
‘Integrated Governance arrangements
representing best practice are in place in
all healthcare organisations and across
all healthcare communities and clinical
networks’
14
Healthcare Standards for Wales
Standard 27
Governance arrangements representing best practice are in place
which:
a) apply the principles of sound clinical and corporate governance;
b) ensure sound financial management and accountability in the use
of resources;
c) actively support all employees to promote openness, honesty,
probity, accountability, and the economic, efficient and effective use
of resources;
d) include systematic risk assessment and risk management; and
e) are integrated across all health communities and clinical networks.
15
Healthcare Standards for Wales
16
Have sustainable systems outlining
accountability and
• Board Code of arrangements,including
Conduct based on
• Internal audit arrangements to
Nolan principles and a system for
include non financial audit and
communicating the Code
• Induction process for new directors
and senior staff
• Induction process(es) for all staff
• Scheme of delegation and schedule
of reserved decisions
• Register of interests
•
System of
Integrated
Governance
• Statement of internal control which
identifies the sources of
assurance…..
management audit
• Audit Committee -according to
recommendations of Audit
Committee Handbook
• Assurance
Framework
• Accountability arrangements for
partnerships and networks
• Governance and Risk
Management Policy/Strategy;
over-arching to cover all
services……
17
Assurance Framework &
Risk Sensitivity
• What are our top 10 strategic objectives?
• Have we identified the risks which might
compromise the achievement of these?
• Are there gaps in controls?
• Are there gaps in assurance?
• Are there plans to mitigate these?
18
Top 10 Key Actions
1. Establish & revisit Clarity of Purpose, strategic (national and local) objectives
2. Establish strategic annual cycle of business, with all agendas integrated
3. Ensure integrated assurance system in place
4. Move to decision making supported by intelligent information
5. Create a streamlined committee structure with clear TOR & delegation and
reporting
6. Set up a strengthened audit committee to scrutinize all Trust activities
7. Establish effective Board supports eg by appointing company secretary to
support Board & Committees and to head compliance unit
8. Establish processes to ensure Board fitness for purpose through selection,
induction and review of Board members
9. Agree and apply Board etiquette
10. Develop individual executive and non executive directors to ensure Board
corporacy
19
Top 10 Key Actions
1.Establish & revisit Clarity of Purpose, strategic
(national and local) objectives
2.Establish strategic annual cycle of business,
with all agendas integrated
3.Ensure integrated assurance system in place
4.Move to decision making supported by
intelligent information
5.Create a streamlined committee structure with
clear TOR & delegation and reporting
20
Top 10 Key Actions
6. Set up a strengthened audit committee to scrutinize
all Trust activities
7. Establish effective Board supports eg by appointing
company secretary to support Board & Committees
and to head compliance unit
8. Establish processes to ensure Board fitness for
purpose through selection, induction and review of
Board members
9. Agree and apply Board etiquette
10. Develop individual executive and non executive
directors to ensure Board corporacy
21
1
Establish & revisit Clarity of Purpose,
strategic (national and local) objectives
Are we clear of our purpose ?
Has it changed, if so does this impact on our strategic objectives,
structures and requirements for staff, buildings, information etc
Do we have temporary purpose, eg merger and do we have capacity to
deliver
What can we afford to give up?
Apply Best Value principles
• Do we need this service – ask consumers
• DO WE need to provide it
• Does it compare with the best
• If we are a monopoly, can we create alternative & better
providers
22
2
Establish strategic annual cycle of business,
with all agendas integrated
April
May
June
July
Sept
October
Nov
January
Feb
March
Strategy
Operational
Performance
Risk
Regulatory
Other
23
3
Ensure integrated assurance
system in place
24
4
Move to decision making supported
by intelligent information
Decision Making: the process.. involving all
stakeholders
Decision Taking: the actual decision …having
considered all the facts and agreed a preferred
option
Never note, always decide
Always end in ‘in order that’ or ‘by means of’
25
Intelligent Information?
26
Intelligent Information?
Intelligent Information Items:
• Have validity, specificity, acceptability and comparability
• Are analysed using robust and acceptable methods
• Can be combined with other intelligent information items to multiply their
power
Intelligent Information Systems:
• Collect only information of value and only collect it once
• Use the most robust and appropriate analytic methods (context determined)
• Learn and improve over time.
Intelligent Information Dissemination:
• Will be appropriate to audience and context
• Will allow meaningful and accurate comparisons to be made
• Will stimulate improvement by saying why? as well as what?
• Will simplify and scintillate
27
5
Create a streamlined committee
structure with clear TOR &
delegation and reporting
Integrated Board
Board
Company
Company
Secretary
Secretary
Appointments
Appointments
&& Remunerations
Remunerations
Committee(s)
Committee(s)
Temporary
Temporary
Committee(s)
Committee(s)
Task
Task && Finish
Finish
Group
Group
Audit
Audit
Committee
Committee
Task
Task && Finish
Finish
Group
Group
Systems & processes
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6
Set up a strengthened audit committee
to scrutinize all Trust activities
‘critical scrutiny role of this committee
to ‘review the establishment and
maintenance of an effective system
of integrated governance, risk
management and internal control
across the whole of the
organisations activities’
Audit Committee Handbook 2005
29
6
Set up a strengthened audit committee to
scrutinize all Trust activities: SUI Audits
IAPG Serious Untoward Incident (SUI)
Governance Audit covers NHS-funded or NHS
regulated care involving:• patients, relatives or visitors
• staff
• contractors, equipment, building or property
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7
Establish effective Board supports
eg by appointing company secretary to
support Board & Committees & to head
compliance unit
• ICSA Company Secretary Programme 6 exams
plus network days
• Now 2 cohorts running, third planned
• Induction Days plus
• Corporate Law and Financial Accounting
• Private Sector to include Financial Accounting
and Corporate
• Corporate Governance and Corporate
Administration
• Corporate Financial Management
• Corporate Secretaryship
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9
Agree and apply Board
etiquette
Mutual trust and respect, honesty
Commitment: to attend, reading briefings, arriving on time and
participating wholeheartedly. Tell our offices we are not to be
disturbed
Determination, Tolerance and Sensitivity:
Rigorous & challenging questioning, tempered by respect.
Demanding & persistent rather than attacking, crushing or
dismissive.
Tolerant of diverse points of view,
Avoid giving offence - ready to apologise,
Avoid taking offence – stay open to discussion
………….After Common Purpose
32
Etiquette
• Group Support:
–Sensitive to colleagues need for support when challenging or being
challenged.; Group ensures no-one becomes isolated in expressing
their view. All ideas treated with respect
• Confidentiality: Candid not secret, No gossip, or gossip
is shared and aired
• Making the most of time
– Support
the Chair, colleagues and guests in making best use of time to
maximise scope and variety of viewpoints heard.
– Time is well used and individual points are relevant and short
– Allow time for review of performance of each session, did we use our
resources well?
33
8
Establish processes to ensure Board fitness for
purpose through selection, induction and
review of Board members
All Scores (6's removed)
Nonexecutives
Other
member
of staff
Executives
1
2
3
4
5
6
8
9
1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
2
0
2
1
2
2
Share Understanding of Brds Purpose
1
1
2
2
2
2
4
2
2
3
3
2
2
1
4
4
1
2
4
4
1
Remind ourselves of purpose which org exists
2
2
1
3
1
2
4
1
1
2
4
2
2
2
3
3
2
3
4
4
1
Share Understanding of Governance
2
1
2
2
1
1
5
3
1
2
4
1
2
1
2
2
2
3
3
2
1
Governance not bureaucratic
2
4
3
1
2
2
5
3
2
4
3
4
4
2
4
5
2
4
4
5
4
Clear on Board's statutory responsibilities
2
3
2
1
1
2
2
3
1
2
3
1
2
3
2
2
2
2
4
3
1
Understand role as Board members
1
2
3
2
1
1
2
1
1
2
5
2
2
1
4
2
2
2
4
3
1
Discussion more srategic than operational
2
4
2
3
2
3
5
1
3
4
5
3
4
3
4
5
2
4
4
3
4
disengage from clinical services as well as develop new
opportunities
3
3
4
3
3
4
5
2
3
4
4
4
5
2
5
5
2
4
4
5
4
Bd's committees designed to ensure effective governance
2
2
4
2
3
3
5
4
3
4
4
4
4
2
3
5
3
5
4
5
2
Set out terms of ref & workplans for committees
3
3
1
2
4
5
4
2
4
2
3
4
5
2
3
5
3
4
4
5
2
Affirming the Board's Purpose
Sufficient support for Board to ensure obligations met and
follow up on commitments made
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1
2
2
2
3
3
3
2
2
4
5
3
2
3
4
4
3
4
4
3
2
10
Develop individual executive and
non executive directors to
ensure Board corporacy
– observation of the Board, Audit Committee and
Governance committees. This will reflect on the scope
of the decision taking processes
– self Assessment and interviews of Board Members to
clarify purpose, corporacy and progress with
reenergising governance agenda
– review with internal auditors of serious untoward
incidents, complaints and regulator prompted action
plans
– review of committee structures to ensure fitness for
purpose
– review with auditors of documentation including
agendas and minutes
– Mock board to board re FT/FFP
35
Self Assessment
Key Elements:
Progress Levels:
NO
1:
Basic level Principle Accepted
2:
Basic level
agreement of commitment
and direction
3:
Early progress in
development
4:
Firm progress in
development
1.Clarity of Purpose
aligned to objectives
and intent
NO
National targets and local
priorities agreed with
stakeholders and plans in
place.
Purpose debated and agreed;
priorities and drivers
established.
Purpose is affirmed in
public and internal
documents.
Board has mechanism
for adding and
removing services
and/or care settings.
1.Strategic annual
agenda cycle with all
agendas integrated
encompassing
activity, resources and
quality
NO
Annual cycle of Board
activity established.
Board papers required to
consider clinical, finance,
HR, H&S etc. implications.
Annual cycle of Board
activity in place;
reporting format and
strategic prioritisation in
place.
Cycle of Business is
tested for strategic
balance.
1.Integrated
Assurance System in
place
NO
Board has understood and
recognised role of assurance
framework
Assurance Framework
covers activity, quality and
resources and realigned to
targets, standards and local
priorities
Control mechanisms in
place for all elements of
the Assurance
Framework
Assurance Framework
is focused on key
business issues;
operational risk is
managed at point of
delivery
36
Self Assessment
Key Elements:
Progress Levels:
NO
1:
Basic level Principle Accepted
2:
Basic level
agreement of commitment
and direction
3:
Early progress in
development
4:
Firm progress in
development
1.Clarity of Purpose
aligned to objectives
and intent
NO
National targets and local
priorities agreed with
stakeholders and plans in
place.
Purpose debated and agreed;
priorities and drivers
established.
Purpose is affirmed in
public and internal
documents.
Board has mechanism
for adding and
removing services
and/or care settings.
1.Strategic annual
agenda cycle with all
agendas integrated
encompassing
activity, resources and
quality
NO
Annual cycle of Board
activity established.
Board papers required to
consider clinical, finance,
HR, H&S etc. implications.
Annual cycle of Board
activity in place;
reporting format and
strategic prioritisation in
place.
Cycle of Business is
tested for strategic
balance.
1.Integrated
Assurance System in
place
NO
Board has understood and
recognised role of assurance
framework
Assurance Framework
covers activity, quality and
resources and realigned to
targets, standards and local
priorities
Control mechanisms in
place for all elements of
the Assurance
Framework
Assurance Framework
is focused on key
business issues;
operational risk is
managed at point of
delivery
37
Stepping up to
whole system governance
•
•
•
•
•
Cancer Networks
Patient Pathways
Social Services
Second Choice Scheme
Private & Voluntary Sectors
38
Whole Health Economy
Assurance Frameworks
Questions to ask
• Can the LHB afford the activity we are providing?
• What assurance do we have that private providers meet
the standards we expect?
• Do we have clinical engagement for the reforms we are
making?
• Do we have political, public and media buy in to the
changes?
• Are we (and our partners) being brave enough?
• Do we (and our partners) follow through on our
decisions?
39
CHANDOS HOUSE rules
for good governance
•
•
•
•
•
Meet in Public
Make partnerships work for you
Learn from failures
Focus on purpose
Step up to the role of governance for
public good
• Success equals freedom
• Ask the daft questions
40
What next?
• What needs to be done?
• What systems, behaviours or relationships
need to change?
41
Contact details
Dr John Bullivant
[email protected]
07775524390
[email protected]
42

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