1: Systems integration and alignment

The board’s job is to be strategic, to look forward and up. But it must have confidence that strategies are being delivered, decisions are being acted upon and that all staff understand their roles and responsibilities.

Board members will have a number of systems and supports to build assurance that these are happening but they must be prepared to ask the right questions and support each other in securing an acceptable response.

Key things to look for are:

• • • Annual Cycle of Business: A planned programme for the year ensuring board meetings cover the key annual events and anticipate critical decision taking.The cycle of business allows boards to plan their away day programme to ensure they cover emerging issues and help to shape national and local strategies.
    • Board assurance framework: A top down listing of key objectives with risks identified together with controls and assurance. Where there are gaps in controls or assurance, action plans will be identified.
    • Decision tracking systems: that records decisions taken by the board, its sub committees and partnership boards.
    • Internal and external audit: Audit plans will be drawn up with the internal and external auditors to ensure systems are working in all areas of activity and thatthere is a strategy for alignment with clinical audit that includes an annual plan addressing national and local priorities.
    • Board Assurance Prompts: that identify key clinical and assurance areas that boards should address and provide some guidance on the kinds of questions that should be asked and what acceptable and unacceptable responses look like. In gaining an overall view of the organization, boards also need to consider the different themes and streams of governance.

There are ten key elements that need to be considered to ensure effective overall and connected governance:

1. 1. 1. Clarity of purpose aligned to objectives andintent
      2. Strategic annual agenda cycle with all agendas integrated encompassing activity, resources and quality
      3. Board Assurance System in place
      4. Decision-taking supported by intelligent information
      5. Streamlined committee structure; clear terms of reference and delegation;time limited
      6. Audit Committee strengthened to cover all governance issues
      7. Development & review of board members
      8. Appointment of a Board Secretary
      9. Board etiquette agreed
      10. Annual Board review

2: Whole system: governance between organizations

Problems often occur at the borders between one organization or team and another. Learning from Investigations In the absence of formal governance arrangements, responsibility for supporting the governance of partnerships falls to partners’ own corporate governance mechanisms.

The NHS works across organizational boundaries and in partnership with other organizations in the interest of patients, local communities and the wider population. The NHS is an integrated system of organizations and services bound together by the principles and values now reflected in the Constitution. The NHS is committed to working jointly with local authorities and a wide range of other private, public and third sector organizations at national and local level to provide and deliver improvements in health and well-being.

Ten simple rules for governance between organizations:

Continuity of Business

1. 1. 1. Jointly commission outcomes and connectivity of care pathways from primary through acute,diagnostics, tertiary to community and home.
      2. Patient referral or data: Take the extra step –have they arrived: what has not arrived?
      3. Review and apply lessons from investigations elsewhere (NHS and other sectors). Could it happen here?Partnerships and networks
      4. Jointly audit critical processes across the boundary (clinical, financial, information etc) at appropriate depth & frequency respective to risk.
      5. Be consistent in telling patients/carers what they are entitled to and when they are holding responsibility for their own care.
      6. Check your partners/suppliers have the capacity to deliver their obligations. Mutual Aid and business continuity
      7. Engage with other organizations to support you in case of long term or widespread service collapse.
      8. Establish and test partner forums and networks to coordinate planning and review progress.
      9. Include reputational risks and potential failure of partners and suppliers in the Board Assurance Framework (BAF).
      10. Apply rules for new staff (CRB checks, data handling, competence, qualifications etc) to existing and agency staff.

3: Annual cycle of business

An effective board will set out a programme for the year ensuring its board meetings cover the key annual events and anticipate critical decision taking. The programme will of course change but this allows the board to ensure that:

• • • committees of the board are clear by when they must conclude business and scrutiny,
    • annual surveys of staff and patients inform plans,
    • regulators and audit reports are prepared and presented in a timely manner,
    • the board can meet to receive and sign off key documents such as the annual accounts, statement of
    • internal control, compliance against standards and the annual report,
    • boards and committees can revisit strategies and influence annual plans

The cycle of business should include assigned and protected time for boards to consider emerging issues and help to shape national and local strategies.The impact of an annual cycle of business is likely to raise more issues than can be accommodated in monthly meetings but this will drive a thoughtful approach to delegated authority to officers and sub committees and encourage more analysis to be put into routine finance, performance and risk reports.

4: Annual board review

The Corporate Governance Code expect the board to undertake a formal and rigorous annual evaluation of its own performance and that of its committees and individual directors. Individual evaluation should aim to show whether each director continues to contribute effectively and to demonstrate commitment to the role (including commitment of time for board and committee meetings and any other duties).

The organization will undertake a formal annual board review covering the whole range of the board’s activities including strategy and operational performance to ensure it has mature processes in place covering:

• • • purpose and vision
    • strategy and planning
    • leadership
    • finances
    • risk and agility
    • information, analysis and assurance
    • quality, efficiency, innovation and outcomes
    • probity and reputation
    • decision making and decision taking
    • service user, staff, stakeholder and public engagement
    • board supports and main committee structures
    • appraisal process of trustees, and other feedback.

5: Training 

The Corporation shall provide an orientation program for first-time directors and relevant annual continuing training for all directors to promote effective board performance and continuing qualification of the directors in carrying-out their duties and responsibility.

6: Clinical audit Clinical audit was originally a process by which clinicians reviewed their own practice, but is now recognized as capable of giving information and assurance about clinical quality as a whole.

Ten simple questions for boards

1. 1. 1. Clinical audit can be used as a strategic tool; your organisation’s clinical audit strategy should be allied to the broader interests and targets that the board needs to address.
      2. There should be direction and focus on how and which clinical audit activity will be supported in the organization.
      3. There should be appropriate processes for instigating clinical audit as a direct result of adverse clinical events, critical incidents, and breaches in patient safety.
      4. The clinical audit programme should be checked for relevance to board strategic interests and concerns. It is important that results are turned into action plans, followed through and re-audit completed.
      5. There should be a lead clinician who manages clinical audit within the organization, and who is clearly accountable at board level.
      6. Patient involvement should be considered in all elements of clinical audit including priority setting, means of engagement, sharing of results and plans for sustainable improvement.
      7. Clinical audit should be built into and inform planning, performance management and reporting.
      8. Clinical audit should cross care boundaries and encompass the whole patient pathway.
      9. The criteria of prioritisation of clinical audits should balance national and local interests, and the need to address specific local risks, strategic interests and concerns.
      10. Check if clinical audit results and complaints are evidence based and if so, develop a system whereby complaints act as a stimulus to review and improvement.