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Home > Typical Assignments > Integrated Governance
Integrated Governance
Introduction
For some time many NHS boards have been aware that their governance arrangements have been too complex, leading to inefficiencies and ineffectiveness. The overlapping strands of clinical governance, controls assurance, or financial governance. and the competing demands of performance management data and regulations have led to unnecessary duplication of activity. Integrated governance can be defined as:-
'Systems and Processes by which Trusts lead, direct and control their functions in order to achieve organisational objectives, safety, and quality services and through which they relate to patients, the wider community and partner organisations'.
Integrated governance provides the umbrella for all NHS governance approaches. It combines the principles of corporate/financial accountability with clinical/management accountability and it moves towards a single risk sensitivity process which covers all the trust's objectives, supported by a coordinated source of collecting information which is subject to co-ordinated inspection.
Integrated Governance is the means by which all the competing pressures on Boards are pulled together. It is clear that all healthcare organisations need to demonstrate that they have strengthened and streamlined their governance arrangements and over time to develop a further integration between health and social care organisations in their health community.
Business Issues
"We know it's complex but we really need to deliver more effective services to our health community, cheaper and faster and without duplication". This quote typifies a pressure that many NHS boards find themselves frequently operating under within the rapidly changing health landscape.
Indeed, in some NHS organisations there is no recognisable single governance approach, simply a collection of silo based activities that attempt to deliver assurance against this fast moving backdrop as well as the pressure to support demanding "Business as usual" targets .
Building or re-building an effective Integrated Governance Capability quickly ,without impacting critical health service delivery ,is a challenge , particularly when there is a need to fit the approach around competing pressures such as existing culture, the health economy and service re-configuration and IT developments to deliver a more modern and effective service to patients. Board members frequently struggle to get the Governance balance right. Too much control, not enough direction, and inadequate information to make informed decisions quickly are common issues they have to deal with.
Approach
At entier we use an approach that we have proven time and time again. This (by necessity) commences with assessing the current governance arrangements and to quickly identify the areas that require urgent attention.
Our approach is intended to help Boards to: challenge the often complex structures of the board and committees;, review the impact of the external environment; and ensure the work of external agencies such as regulators is integrated within the existing assurance framework. The Integrated Assurance Framework can be used as an active internal support to: Board decision making; monitoring compliance with the Department of Health's Standards for Better Health; and to the signing of the Statement of Internal Control (SIC). This means that the approach adopted to ensure compliance with the standards should not add extra burden but is aligned with the existing framework in place.
We work with Board members and the senior management team to define the target requirements for an effective integrated assurance and governance architecture. Then jointly with Board members we define the transition plan to move from the current arrangements to the new integrated governance framework. We pay particular attention to roles and accountabilities at all levels to ensure they are defined and understood. The tools and approaches that underpin our approach are basically simple but flexible enough to accommodate existing practises and cultures.
We then overlay this with a selection of appropriate but basic tools to support change management activity (establishing an integrated Governance capability is a change in itself) to allow a transformation in just a few months. One fundamental principle of our approach lies in the recognition that every organisation is unique and requires some degree of tailoring of the approach.
We work with Board Members and senior management to go through a six stage process to identify:
Principle objectives (strategic and directorate level objectives) ie what the organisation aims to deliver and what standard the objective relates to
Principle risks ie what could prevent this objective being achieved, in particular which area within the NHS organisation this risk primarily relates to
Key controls; in particular what controls/systems we have in place to assist in securing delivery of our objective, and where we can gain evidence that our controls/ systems are effective
Assessment on controls (eg Management checks, Internal Audit, Clinical Audit, Healthcare Commission Annual Health Check, External Audit, Local Counter Fraud Services, NHS Litigation Authority, other reviews)
Board Reports
- positive assurance ie is there evidence that shows the NHS organisation is reasonably managing its risks and objectives are being delivered?
- gap analysis in controls ie where is the NHS organisation failing to put controls/ systems in place and where is it failing to making them effective?
- gap analysis in assurance ie where is the NHS organisation failing to gain evidence that its controls/ systems, on which it places reliance, are effective
Board Action plan to improve control to ensure delivery of principal objectives and gain assurance
Outcomes
Within a few months we frequently receive feedback from client senior managers that confirms that although often painful this is a very worthwhile transition resulting in many positive outcomes:-
- The Board and Senior management feel in control
- Risks are clear and managed improving the chance of successful delivery of critical services to patients
- Staff and management are both clear on roles and accountabilities
- Decisions are made more quickly and in a context where the necessary information is on hand to support them
- Direction of travel is clear and communicated
- Duplications and gaps are removed
- Delivery of critical clinical service is quicker and more efficient.
A key positive outcome for NHS organisations is that compliance with the core standards can be monitored and assured through the existing assurance framework, and a further burdensome approach is not required. For example, the key pieces of national guidance or legislation that trusts should consider during the process of self-assessment should describe what trusts are already doing.
Integrated governance should identify the most relevant items of information to be used for an initial assurance by NHS organisations on their own performance, outcome and output relating to each core standard. Boards can be satisfied that when signing off the statement of internal control (SIC), the core standards have been met and progress is being made towards the developmental standards. This process would be informed by the alignment of the assurance objectives in the assurance framework with the Department of Health's Standards for Better Health.
entier Associates have considerable knowledge of the Annual Health Check through its direct involvement in the launch of the system at the Healthcare Commission. It also has extensive experience of change management, IT, project management, communications and many other management disciplines.
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