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Support in developing governance and compliance functions in an acute hospital trust

Challenge

A trust had been placed in special measures as a result of negative regulator inspections. This revealed deficiencies in its compliance function which had been largely ‘administrative’ to that time – circulating updates from the regulators but playing a limited role in ensuring that actions from alerts are embedded within trust departments. There was weak integration of the compliance team with the internal audit function, leading to a disjointed audit programme.  The trust was in the process of recruiting staff to enhance the compliance unit, but in order to avoid a delay in the restructuring of the unit, the trust required interim support to start the process and to provide expert input into the redesign and implementation of the function.

Scope

Verita delivered support to develop the new compliance unit and to ensure that this is closely aligned with the internal audit function.  That included taking a holistic view of what the regulatory bodies required and how these requirements can be efficiently and effectively delivered to ensure that the system is a genuine means of improving patient safety and experience.

Process

Peter Killwick, company director, and Scott Robertson, a consultant, undertook the work which was carried out in four stages.

  • Stage 1 – Mapping the current situation – the Verita team met with the existing compliance staff and relevant subject leads to discuss the activities they currently carry out and confirm how information flows between teams. We then mapped the processes in place in for each function to produce a standardised set of processes to build upon.
  • Stage 2 – Plan the programme of work – planned and managed the development of the compliance unit and its supporting infrastructure and processes and provided timely updates to the trust on progress and any emerging issues.
  • Stage 3 – Systematic implementation – designed processes for departments using the Process / Activity / Output (PAO) analysis technique using process maps created in stage as the basis for the work.
  • Stage 4 – Training and communication – collaborative implementation and dissemination of the new processes to designed to cultivate staff engagement and ownership of processes.

Findings

Over the course of the project, we found a lack of communication between the senior functions in the trust and those individuals tasked with ensuring that the requirements of the regulators were being met.  This led to a lack of understanding and coherence in both process and information technology terms between individuals ‘on the ground’ and those in senior positions.

Outcome

We developed a holistic approach for the internal audit functions, whereby both systems and processes supported effective ‘two way’ communication in determining what needed to change, how this change should be actioned and how trust systems could be effectively used to demonstrate that the change had been embedded and was working.

 

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