SOUTH EAST COAST AMBULANCE SERVICE NHS TRUST Risk Management and Clinical Governance Committee (RMCGC) Terms of Reference 1. Constitution 1.1. The Board hereby resolves to establish a Committee of the Board to be known as the Risk Management and Clinical Governance Committee (RMCGC), referred to in this document as The Committee. 2. Purpose 2.1. The Committee is responsible for ensuring that the Trust undertakes an integrated approach to the management of clinical governance and all areas of risk. In fulfilling this responsibility the Committee will ensure that the Trust has an appropriate, up to date and co-ordinated range of systems, policies and procedures in place to manage all areas of risk and clinical governance. In so doing the Committee will ensure that risks are identified, assessed, evaluated and managed according to the Risk Management Policy and associated policies and procedures. 3. Membership 3.1. The Committee shall not have less than three members, appointed by the Board from amongst the independent Non-Executive Directors of the Trust. The Chairman of the Trust shall not be a member. One of the Non-Executive Director members will be appointed Chair of the Committee by the Board and this shall not be the Chairman of the Trust. 3.2. The membership comprises: Non-Executive Director (Chair) Non-Executive Director x 2 Director of Clinical Innovation Medical Director Director of Business Development (Lead Executive Director) Director of Operations 3.3. At least two of the members will have a clinical background. 4. Quorum 4.1. The quorum necessary for formal transaction of business by the Committee shall be three members and shall include one Non-Executive Director. 5. Attendance 5.1. The Trust Secretary shall regularly attend meetings. 2010 RiskManagement,ClinicalGovernanceCommittee Terms of Reference_V04 Page 1 of 5
5.2. In addition to the members, the following individuals shall regularly attend meetings of the Committee: Director of Technical Services and Logistics Director of Information Management and Technology Assistant Director of Workforce Development Assistant Director of Finance Head of Risk Management Head of Clinical Governance Head of Patient Experience Patient or User Representative Staff Side Coordinator 5.3. Other organisational managers and officers may be invited to attend meetings for specific agenda items or when issues relevant to their area of responsibility are to be discussed. 5.4. The Trust Secretary s office will provide secretarial duties to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the Chair and Committee members. 5.5. Members and officers unable to attend a meeting are required to send a fully briefed deputy or provide a written update to the Committee members at least two working days beforehand. Members and officers are required to attend 75% of these Committee meetings. 5.6. The Chair of the Committee will follow up any issues related to the unexplained non-attendance of members. Should non-attendance jeopardise the functioning of the Committee the Chair will discuss the matter with the members and if necessary seek a substitute or replacement. 5.7. Attendance at Committee meetings will be disclosed in the Trust s Annual Report and Accounts. 6. Frequency 6.1. Meetings of the Committee will be held every two months and in advance of the next Board meeting to ensure timely reporting. Meeting dates will be diarised on a yearly basis and Extraordinary meetings may be called between regular meetings to discuss and resolve any critical issues arising. The venue for the meetings will rotate around SECAmb to provide visibility and leadership. 7. Chair Action 7.1. Where a matter falling within the authority of the Committee does not permit of delay, the Chair of the Committee in consultation with the Chief Executive and or the Lead Executive Director member of the Committee can take action on behalf of the Committee. All decisions made under Chair Action must be brought to the next scheduled Committee meeting for ratification. 2010 RiskManagement,ClinicalGovernanceCommittee Terms of Reference_V04 Page 2 of 5
8. Telephone Conference With leave of the Chair of the Committee, any member of the Committee may participate in a meeting of the Committee by means of a conference telephone call where circumstances require it or similar communications equipment whereby all persons participating in the meeting can hear each other and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting. 9. Authority 9.1. The Committee has no executive powers other than those specified in these Terms of Reference or by the Trust Board in its Scheme of Delegation. 9.2. The Committee is authorised by the Board to investigate any action within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. 9.3. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers necessary. 10. Duties 10.1. The subject matter for meetings will be wide-ranging and varied but in particular it will cover the following: 10.1.1. To oversee the management of the Risk Register. 10.1.2. To be informed of all relevant visits by external enforcing or inspection bodies, and requests for information from such bodies and to ensure learning from the outcome of these visits is implemented throughout the Trust. 10.1.3. To monitor any risks associated with the performance against Care Quality Commission (and or Monitor) requirements and review the adequacy of risk and control measures related. 10.1.4. To monitor any risks associated with compliance with the NHSLA Ambulance Standards and review the adequacy of risk and control measures. 2010 RiskManagement,ClinicalGovernanceCommittee Terms of Reference_V04 Page 3 of 5
10.1.5. To receive analyses of trends in incidents (including serious untoward incidents), complaints, PALS and claims and ensure that appropriate investigation, learning outcomes and action plans have been identified and implemented. 10.1.6. To ensure systems are in place for the management of any clinical negligence claims, losses and compensation. 10.1.7. To monitor the implementation of best practice guidelines including NICE, JRCALC, national and local guidelines and National Service Frameworks. 10.1.8. To identify and agree annually risk management and clinical governance key performance indicators (KPIs) and monitor progress against them throughout the year. 10.1.9. To monitor the Trust s compliance with infection control requirements. 10.1.10. To review the adequacy of the Trust s risk management and clinical governance policies ensuring there is compliance with relevant regulatory, legal and code of conduct requirements. 10.1.11. To monitor clinical audit plans and receive clinical research and development updates. 10.1.12. To review the Trust s Risk Management Policy annually. 11. Reporting 11.1. The Committee shall be directly accountable to the Trust Board. The Chair of the Committee shall report a summary of the proceedings of each meeting at the next meeting of the Board and draw to the attention of the Board any significant issues that require disclosure. 12. Support 12.1. The Committee shall be supported by the Trust Secretary s office and duties shall include: 12.1.1. Agreement of the meeting agendas with the Chair of the Committee; 12.1.2. Providing timely notice of meetings and forwarding details including the agenda and supporting papers to members and attendees in advance of the meetings; 12.1.3. Enforcing a disciplined timeframe for agenda items and papers, as below: i. At least twelve working days prior to each meeting, agenda items will be due from Committee members; 2010 RiskManagement,ClinicalGovernanceCommittee Terms of Reference_V04 Page 4 of 5
ii. At least seven working days before each meeting, papers will be due from Committee members; iii. At least five working days prior to each meeting, papers will be issued to all Committee members and any invited Directors and officers. 12.1.4. Recording formal minutes of meetings and keeping a record of matters arising and issues to be carried forward, circulating approved draft minutes within five working days from the date of the last meeting; 12.1.5. Advising the Chair and the Committee about fulfilment of the Committee s Terms of Reference and related governance matters. 13. Review 13.1. The Committee will undertake a self-assessment at the end of each meeting to review its effectiveness in discharging its responsibilities as set out in these Terms of Reference. 13.2. The Committee shall review its own performance and Terms of Reference at least once a year to ensure it is operating at maximum effectiveness. Any proposed changes shall be submitted to the Board for approval. 13.3. These Terms of Reference shall be approved by the Board and formally reviewed at intervals not exceeding two years. Review Date: November 2010 2010 RiskManagement,ClinicalGovernanceCommittee Terms of Reference_V04 Page 5 of 5