Midland Health Board (MHB)

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Corporate FitnessCommittee StructureApproved By Chief Executive Officer& Senior Management TeamMay 2003Currently in Implementation Phase1Table of ContentsExecutive Summary......................................................................................................................................................................................2Preparation for Corporate Fitness Committee Structure for the Midland Health Board........................................................3Present Committees that have a Corporate Fitness Function:...........................................................................................................3Present Management Structures: .............................................................................................................................................................4Proposed Structures for Discussion..........................................................................................................................................................5Roles and responsibilities within this structure.....................................................................................................................................7Draft and for discussion.Executive Summary.The following document outlines the proposed structures that need to be in place for goal ofCorporate Fitness to be achieved throughout the Midland Health Board.The role of Corporate Fitness is to assure the quality, safety and fairness of healthservice systems. It is accountable for internal and external communications and theimplementation of a service user focus within the Health Board.Quality guru Stephen Shortell states that one of the critical success factors for a system ofquality to be implemented and sustained in a healthcare setting is that suitable structures are inplace. Presently there are many committees and working groups within the Midland HealthBoard, that in addition to their existing terms of reference, have a remit around the CorporateFitness goals. It is proposed that these will continue to function within their present terms ofreference but that under the new Corporate Fitness Committee structure their CorporateFitness function will be more strategically aligned.The organogram outlines the present committees and proposed committees namely the AcuteHospital Site Corporate Fitness Committee the Primary Care Group, the Central ServiceCorporate Fitness Committee and the Regional Corporate Fitness Committee and the linkagesbetween them. Membership and terms of reference are contained in later chapters.The overriding aim of these proposed changes is to ensure integration of the elements ofCorporate Fitness across all levels of the organisation and to ensure that the qualityimprovement objectives of staff and clients are strategically and operationally aligned with thegoals of Corporate Fitness.Draft and for Discussion – September 20023Preparation for Corporate Fitness Committee Structure for the Midland Health Board.Several recent reports in the Midland Health Board have recommended quality structures be inplace to ensure continuous quality improvement within the board. Specifically, the HealthCare Risk Resources International report (2000), the MHB Quality Strategy (2001), the HealthPromoting Hospitals Framework document, the Clinical Audit Discussion Documentrecommend the development of an overall Corporate Fitness Steering Committee. Rather thanset up new committees alongside existing committees that have a remit for corporate fitnessand quality, a working group was established to examine present structures, identify gaps anddevise a cohesive method of examining all corporate fitness issues:Present Committees that have a Corporate Fitness Function:Currently there are a number of committee structures within the Midland Health Board with afunctional remit for Corporate Fitness, for example:· Regional Clinical Audit Committee (mainly membership from acute hospitals thoughrepresentatives for the other care groups are invited to attend). This will be dissolvedunder the proposed new structure.· Regional Health Promoting Hospitals Committee (membership from Acute Hospitalsand the Long Stay units in the HPH network and recently Mental Health)· The Partnership Committees – one in each of the Acute hospitals (others planned in thecommunity) and the Regional Partnership Committee· Health and Safety Committees (12 existing and 11 recommended) as per discussiondocument for the development of site specific safety statements (April 2002)· CECA (Comments, Enquiries, Complaints and Appeals)· Regional Internal Audit Committee.· Regional Policy CommitteeThis list is not by any means exhaustive.As demonstrated on the organogram on Pg. 5 it is proposed these committees will link withthe Regional Corporate Fitness Committee (probably through representatives that are commonto one or more committees).Draft and for Discussion – September 20024Present Management Structures:The following management structures, in support of the Senior Management Team, CorporateTeam and Care Group Directorates, are currently in place:· The Mental Health Sector Management teams (x 6).· The Mental Health Catchment management teams (x 2)· The Mental Health Cojoint catchment management team· The Care Group Executives – one each for Disabilities, Older Persons, Children andFamilies and Child Protection.· Units of Management (UOM) under the Clinicians in Management Initiative in theMidland Regional Hospital.While the present committees and management structures continue to maintain their currentterms of reference, it is proposed that the Corporate Fitness function of these groups will beincorporated into the Corporate Fitness structures proposed in this document. It is proposedthat where current committees exist e.g. the Sector Management Teams in Mental Health andthe Care Group Executives, Units of Management, that Corporate Fitness issues will becomean item on their agenda. These are already multidisciplinary teams with managementrepresentation. (For membership of the Sector Management Teams, Catchment ManagementTeams and Care Group Executives see Appendix 1 and 2).It is envisaged that this will be an evolving structure as over the coming months and yearsfurther committees with a Corporate fitness agenda are established / removed e.g. Consumerpanels, Accreditation Steering Group (ASG).  Therefore continuous monitoring, review andquality improvement of the structure will be maintained.Draft and for discussion.Proposed Structures for DiscussionRegional Corporate Fitness CommitteeMentalHealth StaffLine ManagersSectormanagementteamsHealth andSafetyCommitteesCatchmentmanagementteams (2)CommunityCare StaffLinemanagersCare GroupExecutives (9)Health andSafetyCommitteesRegional Community Services CorporateFitness CommitteeRegionalInternal AuditCommitteeRegionalPolicyCommitteeCECACommitteeAcuteHospital StaffLinemanagersMidland Regional HospitalCorporate Fitness CommitteeHealth and SafetyCommitteesRegionalPartnershipCommitteeCo-jointCatchmentAreaManagementteamRegionalHPHCommitteeAcuteHospitalPartnershipCommittees(3)Primary CareGroupEthicsCommitteeUnits ofManagementCentral Services – HR,Finance, Technical Services6Note, for areas where health and safety committees do not exist line managers will report health and safety risk issues which can not be managedlocally to the relevant Corporate Fitness management structure as follows:- For Acute Hospital Services, Health and Safety risk issues will be referred to the Midland Regional  Hospital Corporate FitnessCommittee- For Mental Health Services, Health and Safety risk issues will be referred to the relevant Sector Management Team- For Community Services, the Health and Safety risk issues will be referred to the relevant Care Group ExecutiveDraft and for discussion.Roles and responsibilities within this structure1. The Chief Executive officer.The overall responsibility for effective Corporate Fitness within the Midland health board lieswith the Chief Executive Officer.  At an operational level, the senior management team areresponsible for Corporate fitness within their sectors of management.2. The General Managers.Responsibilities:· For the effective management of the quality and safety of healthcare within their areas.· Promote the development of a positive and supportive culture within the Midland HealthBoard for the management of all aspects of healthcare risks· Ensure that employees are adequately trained to participant in the implementation of theHealthcare Risk Management Policy, Continuous Quality Improvement and ClinicalAudit. Such training will be co-ordinated by the Corporate Fitness support team in liaisonwith the Human Resource Department and Line Managers.· Ensure that necessary resources are available to meet Corporate Fitness objectives withinoverall resource limitations.· Promote and ensure that Corporate Fitness issues are included at line management, Unitsof Management, Sector management team, Care Group Exectuive meetings.· When required, initiate appropriate measures to deal with serious breaches of, or apersistent disregard for, the Healthcare Risk Management Policy, and associated protocols.· Set a good personal example by actively promoting Continuous Quality Improvement,Audit and review, good Healthcare Risk Management practices.Accountable:General manager is accountable for all of the above to the Senior Management team.83. Units of Management (Midland Regional Hospital only).  Comprises of a ClinicalDirector R, Divisional Nurse Manager and Business Manager.· To receive and act upon Corporate Fitness issues identified by their line managers.· Prioritise areas within their control for Quality improvement, Clinical Audit and RiskManagement and act on these.· Allocate resources including financial resources from discretionary funds available, forthe implementation of control measures, the recommendations of incident/claim reviewsand audit reports and Quality action plans.· If  -· The hazard can not be suitably controlled or the incident/claim reviewrecommendation satisfactorily implemented, or· The recommended changes for quality improvement cannot be implemented by theunit of management ,either because it requires funding greater than is available in local discretionary funds, orbecause it requires greater representation in the decision making process than is affordedby the Unit of Management, it will be referred to the next appropriate forum (MidlandRegional Hospital Corporate Fitness committee )· Identification of training needs for staff and implement training plan based on trainingneeds identified.Accountability.The unit managers are accountable to their Clinical Director  R, Director of Nursing, GeneralManager on all of the above areas.4. Line ManagersResponsibilities:‘Of overwhelming importance is the need to acknowledge at  all times that CQI and riskmanagement are direct line management responsibilities.  Unless all the managers andclinicians within the care groups genuinely believe this, understand what this means and takeappropriate action to achieve such effective operational practices every day, the effectivenessof any central initiatives will be diminished’ (HRRI Report, 2000)· To receive and act upon Corporate Fitness issues identified by their staff· Prioritise areas within their control for Quality improvement, Clinical Audit and RiskManagement and act on these.9· Allocate resources including financial resources from discretionary funds available, forthe implementation of control measures, the recommendations of incident/claim reviewsand audit reports and Quality action plans.· If  -· The hazard can not be suitably controlled or the incident/claim reviewrecommendation satisfactorily implemented, or· The recommended changes for quality improvement cannot be implemented by theline manager ,either because it requires funding greater than is available in local discretionary funds, orbecause it requires greater representation in the decision making process than is affordedby the Line Managers, it will be referred to the next appropriate forum (SectorManagement teams, Units of Management, Midland Regional Hospital CorporateFitness committee or Care Group Executive.· Identification of training needs for staff and implement training plan based on trainingneeds identified.Accountability.The line manager is accountable to their General Manager (or Unit of Management) on all ofthe above areas.5.  StaffResponsibilities:· Quality assurance of work practices.· Identification of areas for Quality improvement, Clinical Audit and Risk Management andreporting of these to their line manager.· Adherance to the 1989 Health and Safety at work legislation.· Implementation of corrective measures/improvements where possible.· Collaboration with Line Managers on those areas that cannot be dealt with by theindividual staff member.· Identification of individual training needs as part of their personal development planning.Accountable:The individual staff member is accountable to their line manager on all of the areas outlinedabove.

Corporate fitness committee structure: approved by Chief Executive Officer & senior management team, May 2003: currently in implementation phase

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