Patient Safety Committee Terms of Reference (186kB pdf)
1. Constitution
1.1 The Patient Safety Committee (the Committee) is established by the Integrated Care Board (the Board or ICB) as a committee of the Board. in accordance with its Constitution, Standing Financial Instructions, Standing Orders and Scheme of Reservation and Delegation (SoRD).
1.2 These Terms of Reference (ToR) set out the membership, remit, responsibilities, and reporting arrangements of the Committee and may only be changed with the approval of the Board
2. Authority
2.1 The Patient Safety Committee is authorised by ICB Board to:
- Undertake any activity within its ToR.
- Seek any information it requires within its remit, from any employee or member of the ICB (who are directed to co-operate with any request made by the Patient Safety Committee) within its remit as outlined in these ToR.
- Commission any reports it deems necessary to help fulfil its obligations.
- Obtain legal or other independent professional advice and secure the attendance of advisors with relevant expertise if it considers this is necessary to fulfil its functions. In doing so, the Committee must follow any procedures put in place by the ICB for obtaining legal or professional advice.
- Create task and finish sub-groups in order to take forward specific programmes of work as considered necessary by the Patient Safety Committee members. The Patient Safety Committee shall determine the membership and ToR of any such task and finish sub-groups in accordance with the ICB’s Constitution, Standing Orders and SoRD but may not delegate any decisions to such groups.
2.2 For the avoidance of doubt, the Patient Safety Committee will comply with, the ICB Standing Orders, Standing Financial Instructions and the SoRD, except as outlined in these ToR.
2.3 The Patient Safety Committee has no executive powers, other than those delegated in the SoRD and specified in these ToR.
3. Purpose
3.1 Under the current NHS Operating Model and Strategic Commissioning Framework the key requirements for quality oversight in an ICS published by the National Quality Board remain. All health and care organisations remain accountable for quality and have a responsibility to work together to proactively share intelligence, drive improvement and mitigate and escalate quality risks.
3.2 The ICB Patient Safety Committee will undertake assurance and oversight on behalf of the ICB for the identification, monitoring and escalation of quality, safeguarding and ICB operational performance issues in relation to ICB statutory responsibilities and duties. The Commissioning Strategy Committee will consider the quality of commissioned services as part of its role in assuring the delivery by providers of services commissioned by the ICB.
3.3 The ICB Patient Safety Committee will provide oversight and assurance to the Board that the ICB continues to meet its responsibilities for system quality as defined by the National Quality Board. The Committee is established to ensure that the ICB is delivering its functions in a way that secures continuous improvement in the quality of services, against each of the dimensions of quality set out in the Shared Commitment to Quality and enshrined in the Health and Care Act 2022.
3.4 The committee will provide oversight and assurance to the Board and that where NHSE have requested targeted measures for improvement through contractual levers these are being monitored and actioned.
3.5 The Committee exists to scrutinise the robustness of, and gain and provide assurance to the ICB, that there is an effective system of quality governance and internal control that supports it to effectively deliver its strategic objectives and provide sustainable, high-quality care.
3.6 The duties of the Patient Safety Committee will be driven by the organisation’s objectives and the associated risks. An annual programme of business will be agreed before the start of the financial year; however, this will be flexible to new and emerging priorities and risks.
4. Responsibilities of the Patient Safety Committee
4.1 Specific responsibilities of the Committee are as follows:
4.2 The Committee is responsible for ensuring the robustness of the systems in place across the ICB to secure effective quality and safeguarding governance and assurance. As such the Committee will approve arrangements to minimise clinical risk and maximise patient safety.
4.3 The Committee will ensure that these systems and processes allow the ICB to comply with all relevant legislation and national guidance, to effectively deliver its strategic objectives and commission sustainable, high-quality care whilst also ensuring appropriate safeguards are in place to protect the most vulnerable.
4.4 The Committee will approve arrangements for supporting NHS England in discharging its responsibilities in relation to securing continuous improvement in the quality of general medical services.
4.5 The Committee will provide assurance that the ICB is meeting its system level responsibilities as defined by National Quality Board (NQB) in that the ICB is expected to:
- maintain System Quality Groups (SQG) as a forum for intelligence sharing and partnership working to improve quality.
- ensure the SQG has representation from all system partners as per the NQB guidance, including Integrated Health Organisations (IHO) as appropriate.
- review SQG footprints, aligning with cluster/ merged footprints as appropriate.
- be represented at the Regional Quality Group, ensuring effective escalation.
4.6 The Committee will receive reports from the System Quality Group (SQG) to review and identified themes and shared learning from Serious Case Reviews, Adult Learning Reviews and Domestic Homicide reviews drawing on intelligence and collaboration with place based Local Safeguarding Partnerships, Safeguarding Boards and Safer Community Partnerships, working collaboratively with ICB partners to do so.
4.7 Oversee and scrutinise the ICB’s response to all relevant directives, regulations, national standard, policies, reports, reviews inspections, and best practice as issued by the Department for Health and Social Services (DHSC), NHS England and other regulatory bodies / external agencies (e.g. the Care Quality Commission (CQC), National Institute for Health and Care Excellence (NICE).
4.8 Maintain an overview of changes in the methodology employed by regulators and changes in legislation/regulation and assure the ICB that these are disseminated and implemented across all sites.
4.9 Receive assurance that the ICB has effective and transparent mechanisms in place to monitor mortality and that it learns from deaths (including coronial inquests and Prevention of Future Death reports).
4.10 Provide the ICB with assurance that it is delivering its statutory duties for safeguarding adults, children, children looked after and Special Educational Needs and Disability as laid out in Section 11 – The Children Act, 2004, Working Together to Safeguard Children, 2018, The Care Act, 2014, Promoting the Health and Wellbeing of Looked After Children 2015, SEND code of practice 0- 25yrs, 2015.
4.11 Comprehensively scrutinise the robustness of the arrangements for, and assure compliance with, the ICB’s statutory responsibilities for:
- infection prevention and control.
- medicines optimisation and safety.
- equality and diversity where these relate to specific performance standards or matters of care quality.
4.12 To arrange a rolling programme of deep-dive reviews across both the committee and SQG with the aim of understanding in detail key areas of ICB performance and quality and contributing through this process to improvement activities and the promotion of shared learning.
4.13 Ensure that the SQG maintains effective processes for system-wide learning from significant events including themes and trends from incidents and safeguarding reviews. This assurance will be provided via SQG reports and supplementary papers.
The Committee’s role is to ensure that lessons learned are implemented and make a difference.
4.14 Follows National Quality Board guidance to maintain its system level responsibilities for quality on behalf of the ICB. This means the Patient Safety Committee will work in collaboration with other ICB committees (especially Commissioning Committee, the System Quality Group, regional groups for example Regional Quality Group and Joint Strategic Oversight Groups).
4.15 The Committee will receive and review a risk report to agree on the main risks related to quality. Whilst responsibility for detailed review and remedial action on risks rests with the ICB executive leadership, the Committee is expected to maintain an awareness of quality and performance related risks and assure itself that the proposed actions are adequate.
Work in support of the ICB Strategic Commissioning Committee to provide assurance 4.16 that the ICBs responsibilities for contractual oversight of quality are being met.
5. Membership and attendance
Membership
5.1 The Patient Safety Committee membership is as follows:
- Non-Executive Member (Chair)
- Non-Executive Member
- ICB Chief Nursing Officer
- ICB Medical Director
5.2 The role of Committee Chair will be undertaken by a Non-Executive Member (who cannot be the Chair of the ICB or the Audit and Risk Committee Chair).
5.3 Members are required to attend a minimum of 75% of meetings, other than absence due to sickness.
5.4 Members may nominate deputies to represent them in their absence and make decisions on their behalf, subject to the approval of the Chair.
5.5 Members will possess between them knowledge, skills and experience in the issues pertinent to the Patient Safety Committee’s business. When determining the membership of the Patient Safety Committee, active consideration will be made to diversity and equality. Chair and Vice Chair
5.6 The Patient Safety Committee will be chaired by a member appointed on account of their specific knowledge skills and experience making them suitable to chair the Patient Safety Committee.
5.7 Patient Safety Committee members may appoint a Vice Chair who will be nominated by the Chair of the Patient Safety Committee. If the Committee Chair is absent or is disqualified from participating by a conflict of interest, the Vice Chair, if present, shall preside. If the Chair or Vice Chair are absent from any meeting, a Chair shall be nominated by other members attending that meeting.
5.8 The Chair will be responsible for agreeing the agenda and ensuring matters discussed meet the objectives as set out in these ToR. Attendees
5.9 The Patient Safety Committee shall have the following non-voting attendees (as and when required):
- ICB Director of Quality (SRO for Quality)
- Other Directors and/or managers as appropriate;
- Other partners, as required for specific agenda items;
- Representatives from other organisations, as required.
5.10 Attendees may present at meetings and contribute to the relevant discussions but are not allowed to participate in any formal vote.
5.11 Attendees may nominate deputies to represent them in their absence, with agreement of the Chair.
5.12 The Patient Safety Committee may call additional experts to attend meetings on a case-by-case basis to inform discussion.
5.13 The Patient Safety Committee may invite or allow people to attend meetings as observers. Observers may not present at meetings, contribute to any discussion or participate in any formal vote.
5.14 The Chair of the ICB will be invited to attend one meeting each year in order to gain an understanding of the Committee’s operations.
5.15 The Patient Safety Committee Chair may ask any or all of those who normally attend, but who are not members, to withdraw to facilitate open and frank discussion of particular matters.
6. Meeting Frequency, Quoracy and Decisions
6.1 The Patient Safety Committee will usually meet once every two months.
Arrangements and notice for calling meetings are set out in the Standing Orders.
Additional meetings may take place as required.
6.2 The Board, Chair or Chief Executive may ask the Patient Safety Committee to convene further meetings to discuss particular issues on which they want the Patient Safety Committee’s advice.
6.3 Meetings will be held in-person, unless previously agreed by the Chair. The Patient Safety Committee may choose to meet online, via MS Teams or suitable alternative platform. Quorum
6.4 For a meeting to be quorate the following members will be required:
- Non-Executive Member (Chair)
And two of the following:
- Non-Executive Member
- Chief Nurse and Quality Officer
- Chief Medical Officer
6.5 If any member of the Patient Safety Committee has been disqualified from participating in an item on the agenda, by reason of a declaration of conflicts of interest, then that individual shall no longer count towards the quorum.
6.6 If the quorum has not been reached, then the meeting may proceed if those attending agree, but no decisions may be taken.
Decision making and voting
6.7 Decisions will be taken in accordance with the Standing Orders. The Patient Safety Committee will ordinarily reach conclusions by consensus. When this is not possible the Chair may call a vote.
6.8 Only members of the Patient Safety Committee may vote. Each member is allowed one vote and a majority will be conclusive on any matter.
6.9 Where there is a split vote, with no clear majority, the Chair of the Patient Safety Committee will hold the casting vote.
6.10 If a decision is needed which cannot wait for the next scheduled meeting, the Chair may conduct business on a ‘virtual’ basis through email or other electronic communication.
6.11 Any decisions taken virtually must be recorded at the next scheduled meeting.
7. Accountability and reporting
7.1 The Patient Safety Committee is accountable to the ICB Board and shall provide reports to the Board on how it discharges its responsibilities and shall draw to the attention to any issues that require disclosure or require action.
7.2 The Patient Safety Committee shall make any such recommendations to the ICB Board it deems appropriate on any area within its remit where action or improvement is needed.
7.3 The minutes of the meetings shall be formally recorded by the secretary and approved at the next scheduled meeting.
7.4 The Patient Safety Committee will report to the Board at least annually to describe how it has fulfilled its ToR, give details of any significant issues that it has considered, and how they were addressed.
8. Conflicts of Interest
8.1 Conflicts of Interest shall be dealt with in accordance with the ICB Conflicts of Interest Policy.
8.2 The Patient Safety Committee will have a Conflicts of Interest Register that will be presented as a standing item on the agenda.
8.3 All members and attendees of the Patient Safety Committee must declare any relevant personal, non-personal, pecuniary or potential interests at the commencement of any meeting. The Chair will determine if there is a conflict of interest such that the member and/or attendee will be required not to participate in a discussion.
9. Behaviours and Conduct
ICB values
9.1 Members will be expected to conduct business in line with the ICB values and objectives.
9.2 Members of, and those attending, the Committee shall behave in accordance with the ICB’s Constitution, Standing Orders, and Standards of Business Conduct Policy.
Equality and diversity
9.3 Members must demonstrably consider the equality and diversity implications of decisions they make.
10. Secretariat and Administration
10.1 The Patient Safety Committee shall be supported with a secretariat function which will include ensuring that:
- The agenda and papers are prepared and distributed in accordance with the Standing Orders having been agreed by the Chair with the support of the relevant executive lead.
- Attendance of those invited to each meeting is monitored and highlighting to the Chair those that do not meet the minimum requirements.
- Records of members’ appointments and renewal dates and the Board is prompted to renew membership and identify new members where necessary.
- Good quality minutes are taken, agreed with the Chair, and a record of matters arising. Action points and issues, with progress updates, will be carried forward between meetings.
- The Chair is supported to prepare and deliver reports to the ICB Board]; and
- The Patient Safety Committee is updated on pertinent issues / areas of interest / policy developments.
11. Review
11.1 The Patient Safety Committee will review its effectiveness at least annually and recommend any changes it considers necessary to the ICB Board.
11.2 These ToR will be reviewed at least annually and more frequently if required. Any proposed amendments to the ToR will be submitted to the ICB Board for approval.