Star Chamber
Terms of Reference
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Replaces:
003/009/007
V1.0
Compliance Working Group
26th June 2014
Head of Medical Services
June 2014
June 2016
N/A - new ToR’s
Document Control
Manager Responsible
Name:
Nicola Brooks
Title:
Head of Medical Services
Directorate: Medical Directorate
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approve
Version No. V1.00
Final
Date: 26th June 2014
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Compliance Working
For approval
V1.0
26th June 2014
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Star Chamber
For review
V0.1
7th May 2014
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Star Chamber ToR V1
June 2014
Date: June 2014
Date:
Date: June 2016
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STAR CHAMBER
TERMS OF REFERENCE
1.
Constitution
1.1 The Board hereby resolves to establish a Sub Group of the Compliance
Working Group to be known as the Star Chamber.
2.
Purpose
2.1 The NHS Commissioning Board (NHSCB) document ‘Everyone Counts:
Planning for Patients 2013/14’ describes the enablement of excellence in
healthcare and how successes in the future will be judged on the quality of
outcomes. The guidance advises that as the NHS continues to face the need to
improve efficiency at an increasingly faster rate, it is essential that as providers
identify ways to secure cost improvements there is no trade-off with the quality
of services provided. It is the fundamental responsibility of the Boards of
provider organisations to ensure any decisions to reduce costs do not have a
negative impact on the quality of services.
2.2 From April 2013, all Commissioners operate on the basis that any Trust Cost
Improvement Plans (CIPs) have been agreed by their respective Medical and
Nursing Directors as having been assured as clinically safe before being
approved by the Trust Board. The National Quality Board (NQB) guidance
advises how Monitor would regard the failure of Foundation Trust Board
members to agree plans as a sign of poor governance.
2.3 The NQB ‘How to’ guidance provides a specific framework for the QIA of
provider CIPs and describes how Trust Boards are responsible for bringing
together all the available information to ensure that a sufficiently granular level
of triangulation and assessment is formally undertaken and reported to the
Trust Board. It defines how it is the collective responsibility of the Board to
ensure that a full appraisal of the Quality Impact Assessment (QIA) is
completed and recorded and that arrangements are put in place to monitor
work going forward.
2.4 The guidance recommends the establishment of a Star Chamber led by the
Medical and Nurse Directors and including key Director level staff from areas
such as quality, workforce, finance and performance to serve as a reliable
forum for robust and challenging conversations concerning both qualitative and
quantitative data and intelligence about the organisation. Judgements made
should be fair, transparent and proportionate and are best taken by Board
Directors in line with formal governance arrangements. Devolving responsibility
to sub-board level staff for the stages of assessment beyond straightforward
data compilation and analysis is likely to compromise the integrity of the
process. In addition the degree of judgement required about the acceptability of
the assessment or need for further examination of the situation is best done by
Star Chamber ToR V1
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experienced Directors, principally, but not exclusively the Medical and Nurse
Directors.
2.5 The Star Chamber will therefore provide assurance to the Executive Team,
Compliance Working Group, Risk Management and Clinical Governance
Committee and Lead Quality Commissioner that the Trust has identified
programmes to secure the annual cost improvement plans (CIPs) that do not
jeopardise the quality of services provided.
3.
Membership
3.1 The Star Chamber shall be led by the Medical and Nurse Directors and include
key Director level staff from areas such as quality, workforce, finance and
performance to serve as a reliable forum for robust and challenging
conversations concerning both qualitative and quantitative data and intelligence
about the organisation.
3.2 The membership comprises:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
4.
Medical Director (Chair)
Director of Clinical Operations (Vice Chair)
Director of Nursing and Urgent Care
Director of Commercial Services
Director of Finance
Head of Medical Services
Head of Compliance
Head of Operational Business Development
Interim Head of Finance
Medical Directorate Administrator
Quorum
4.1 The quorum necessary for formal transaction of business by the Star Chamber
shall be four members.
4.2 The quorum must include an Executive Director and representation from the
Medical, Clinical Operations and Finance Directorates.
5.
Attendance
5.1 Other organisational managers and staff may be invited to attend meetings for
specific agenda items or when issues relevant to their area of responsibility are
to be discussed.
5.2 Members and invited staff unable to attend a meeting are required to send a
fully briefed deputy or provide a written update at least two working days
beforehand.
5.3 The Chair will follow up any issues related to the unexplained non-attendance
of members. Should non-attendance jeopardise the functioning of the Star
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Chamber, the Chair will discuss the matter with the member and if necessary
seek a substitute or replacement.
6.
Frequency
6.1 The Star Chamber will meet on alternate months (six times in a twelve month
period) and members must attend at least four of the meetings on a rolling
annual basis.
6.2 Meeting dates will be diarised on a yearly basis and will aim to follow the
Executive Team meetings.
6.3 If necessary, by the agreement of the Chair, the Star Chamber can convene
additional extraordinary meetings by exception should the agenda dictate such
a requirement.
7.
Chair’s Action
7.1 Where a matter falling within the authority of the Star Chamber requires an
urgent decision, the Chair /Vice Chair as Executive Directors of the Trust can
take action as appropriate.
7.2 All decisions made under such Chair’s Action must be submitted to the next
scheduled meeting for ratification and formal minuting.
8.
Telephone Conferences
8.1 Meetings to undertake the business can be conducted face to face, via
telephone or videoconferencing facilities but must still be quorate.
8.2 With leave of the Chair, any member (or the Star Chamber itself) may
participate in a meeting by means of a conference telephone call where
circumstances require it, or using similar communications equipment whereby
all persons participating in the meeting can effectively hear each other.
8.3 Participation in the meeting in this manner shall be deemed to constitute
presence in person at such meeting.
9.
Authority
9.1 The Star Chamber has no executive powers other than those specified in these
Terms of Reference.
9.2 The Star Chamber is authorised by the Compliance Working Group 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.
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10.
Duties
10.1 The Star Chamber will identify critical indicators to inform the overall
assessments, supported by the Commissioners whose role it is to both validate
the assessments and complete an overview of the locality and any cross cluster
or sector issues. Such triangulation of information and perspectives helps
promote process reliability and validity.
10.2 To support decision making processes the national guidance suggests Trusts
should use local and nationally accredited tools such as the National Quality
Dashboard (NQB) “How To” guides, the NHS Safety Thermometer and any
likely impacts on staff and patient surveys, including the Friends and Family
Test. In addition, the Trusts clinical leaders must confirm planned CIPs do not
contravene NICE guidance.
10.3 Serious incidents and patient experience data should be continuously
monitored for important triggers, alerts or trends which could suggest
unintended or negative consequences for patients and/or staff. Detailed
reference to patient safety/experience metrics is crucial and should include for
example, mortality rates, patient experience indicators, trainee voice, safety
thermometer harms, complaints, media profiles, patient choice data,
compliance with CAS alerts and adult/child safeguarding reports.
10.4 The Star Chamber will:
10.4.1 During Q3/Q4 each year, review and agree all CIP proposals and associated
QIAs for the forthcoming year and prior to implementation, including:
a) Benefits for patients
b) Links to quality indicators
c) Impact details for each of the quality domains of patient safety, clinical
effectiveness and patient experience
d) Narrative on what potential impacts may be
e) Details of any mitigation plans
f) The QIA risk assessment
g) Overall QIA score (automatically set to the highest score seen across
the three domains)
10.4.2 Review the extent of change and impacts to the organisations footprint.
10.4.3 Regularly monitor the implementation of each CIP ensuring any necessary
remedial action plans are developed and monitored, and particularly in
addressing gaps in control or assurance, clinical risks, assessment
requirements and any relevant regulatory, legal and code of conduct
requirements.
10.4.4 Ensure a cross-directorate culture that promotes a supportive approach to
clinical governance, quality and risk management.
10.4.5 Approve the Star Chambers Terms of Reference and Annual Agenda
Framework.
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10.4.6 Be informed of all relevant visits by external enforcing or inspection bodies
with regards to the QIA of CIPs and to ensure learning from the outcome of
these visits is implemented throughout the Trust.
10.4.7 Ensure appropriate and timely submission of required plans and reports to
the Executive Team, Compliance Working Group, Risk Management and
Clinical Governance Committee and Lead Commissioners.
11. Reporting
11.1 The Star Chamber shall be directly accountable to the Compliance Working
Group.
11.2 Summary update reports will be submitted to the Compliance Working Group,
the Risk Management and Clinical Governance Committee and the Lead
Quality Commissioner as required.
11.3 The reports will draw to the attention of the above Groups any significant issues
that require escalation and/or disclosure.
12. Support
12.1 The Star Chamber will be supported by the Medical Directorate Administrator.
These duties shall include:
12.2 Agreement of the meeting agendas with the Chair.
12.3 Providing timely notice of meetings and forwarding details including the agenda
and supporting papers to members and attendees in advance of the meetings.
12.4 Enforcing a disciplined timeframe for agenda items and papers, as below:
a) At least twelve working days prior to each meeting, agenda items will be due
from the members;
b) At least seven working days before each meeting, papers will be due from the
members;
c) At least five working days prior to each meeting, papers will be issued to
members as appropriate.
12.5 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. (Meetings may be voice
recorded for administrative purposes only. Any such recordings will be deleted
once the minutes have been transcribed and will not be available under the FOI
Act.)
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13. Review
13.1 The Star Chamber 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 Star Chamber will agree an annual Agenda Framework to ensure it
complies with the duties defined in this Terms of Reference.
13.3 The Star Chamber shall review its own performance at each meeting and
Terms of Reference every two years or soon if required to ensure it is operating
at maximum effectiveness. Any proposed changes will be submitted to the
Compliance Working Group.
13.4 These Terms of Reference shall be approved by the Compliance Working
Group and formally reviewed at intervals not exceeding two years.
Approved by:
Compliance Working Group
Approved date:
26th June 2014
Review Date:
June 2016
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