HCAI Reduction Reviews enquiries into breaches and agrees remedial Plan/Infection Control action Regulatory Compliance Ensures the Fed meets the requirements of its CQC regulators including addressing policy changes CIC Regulator Reviews the conclusions from self-assessments and Commissioners inspections Monitors how well we meet contractual requirements Information Governance Ensures the Fed complies with the Law, NHS guidance Confidentiality via the IG Toolkit and local CCG’s Data Protection Reviews investigations into breaches and agrees Information Security remedial action plans Freedom of Information Quality of clinical record keeping Risk Management Ensure a culture throughout the organisation ‘risk Health & Safety and assessment of risk is part of all work activities Office Security through a top down and bottom up approach. Risk Assessment Agrees risk and associated policies (including clinical risk and Monitors compliance with all the statutory and mitigation) standards relating to the assessment and Business Continuity control of risk Planning (BCP) Monitors the Federation’s BCP and DRPs Disaster Recovery Planning (DRP) Workforce Ensures we have a motivated and appropriately skilled Recruitment workforce Induction Ensure we have appropriate HR systems and Professional Registration processes across the organisation and reflect best Mandatory Training practice, regulatory requirements and legislation Continuing Professional Reviews the outputs from our HR systems Development Appraisals & 1:1’s Performance Management Management of conflicts/grievance Clinical Supervision Peer Support & Review Staff Surveys Patient Experience Review indicators of patient experience. Patient Access Ensure patients understand that they can expect from Open our services, how services are accessed and wait times Patient Involvement & Ensure we are open and transparent when mistakes Surveys are made Ensure we have systems so patients are involved with developing our services Monitor and act on patient feedback to ensure we can develop and improve our services Review quality indicators Quality Assurance Performance Monitoring Ensure there are appropriate systems for collecting Complaints Handling complaints and incidents/issues Incident Reporting appropriate, review complaints and incidents/issues, develop and disseminate learning Clinical Effectiveness Ensure there are systems which assess the clinical NICE Guidance effectiveness of services
HCAI Reduction Plan/Infection Control Reviews enquiries into breaches and agrees remedial action Regulatory Compliance CQC CIC Regulator Commissioners Ensures the Fed meets the requirements of its regulators including addressing policy changes Reviews the conclusions from self-assessments and inspections Monitors how well we meet contractual requirements Information Governance Confidentiality Data Protection Information Security Freedom of Information Quality of clinical record keeping Ensures the Fed complies with the Law, NHS guidance via the IG Toolkit and local CCG’s Reviews investigations into breaches and agrees remedial action plans Risk Management Health & Safety Office Security Risk Assessment (including clinical risk and mitigation) Business Continuity Planning (BCP) Disaster Recovery Planning (DRP) Ensure a ‘risk culture throughout the organisation and assessment of risk is part of all work activities through a top down and bottom up approach. Agrees risk and associated policies Monitors compliance with all the statutory and standards relating to the assessment and control of risk Monitors the Federation’s BCP and DRPs Workforce Recruitment Induction Professional Registration Mandatory Training Continuing Professional Development Appraisals & 1:1’s Performance Management Management of conflicts/grievance Clinical Supervision Peer Support & Review Staff Surveys Ensures we have a motivated and appropriately skilled workforce Ensure we have appropriate HR systems and processes across the organisation and reflect best practice, regulatory requirements and legislation Reviews the outputs from our HR systems Patient Experience Patient Access Open Patient Involvement & Surveys Review indicators of patient experience. Ensure patients understand that they can expect from our services, how services are accessed and wait times Ensure we are open and transparent when mistakes are made Ensure we have systems so patients are involved with developing our services Monitor and act on patient feedback to ensure we can develop and improve our services Quality Assurance Performance Monitoring Complaints Handling Incident Reporting Review quality indicators Ensure there are appropriate systems for collecting complaints and incidents/issues appropriate, review complaints and incidents/issues, develop and disseminate learning Clinical Effectiveness NICE Guidance Ensure there are systems which assess the clinical effectiveness of services