The following Terms of Reference set out the responsibilities of the National ICU Audit Governance Committee, under the governance structures established by the National Office of Clinical Audit.
The Clinical Lead and the ICU Audit Coordinator shall be responsible for the administration of the ICU Audit Governance Committee.
ICU Audit Governance Committee requires the presence of six of its members in attendance to establish a quorum for any meeting convened. The Clinical Lead and ICU Audit Coordinator will report to and attend all Governance Committee meetings. The Clinical Lead will hold voting entitlement at the Governance Committee.
Procedures for the appointment of members
It has been agreed through the NOCA Governance Board, that in order to establish the National ICU Audit Committee the Clinical Lead for Audit will chair the Committee for the first six months. Subsequent Chairpersons will be elected from the overall membership of the Governance Committee.
Membership of the ICU Audit Governance Committee will be for a staggered period of two years. Members will be selected to reflect the interests of the ICU clinical community as a whole and to achieve an appropriate mix of relevant skills to support ICU audit under the Governance of NOCA. The number of other positions held by candidates will be considered so that candidates are not over burdened and will have appropriate time to commit to ICU Audit. If the Committee decides that further nominations are required for the ICU Governance Committee, these will be invited to join by the Chair in consultation with the Committee.
Resignation of Governance Committee Members
Membership of the ICU Governance Committee will be for a period of two years. Resignation before completion of tenure will be tendered and accepted only in writing to the Chair and will allow for no less than two months notice. In the case of resignation of an individual, who may have been involved, or offering specific advice or guidance in respect of the completion on any particular audit output or report, the Committee Member will first ensure all obligations are fully discharged before tendering resignation. The Chair shall invite additional members to fill casual vacancies from relevant cohort or as the need arises in order to ensure adequate expertise is represented.
It is intended the ICU Governance Committee will meet quarterly. Prior notice will be issued by email. In the event a member is not in a position to attend, apologies should be sent to the ICU Audit Clinical Lead / ICU Audit Coordinator in advance. If a member of the Committee cannot attend it is not appropriate to send an alternate.
The operation of the Audit must be totally confidential. Members of the Governance Committee are nominated by various bodies and part of their role is to keep these bodies informed about developments in ICU Audit. However it would be a major breach of professional confidentiality to divulge any information about specific quality of care issues which may be discussed at the Governance Committee.
Management of Conflicts of Interest
In order to ensure the ICU Audit Governance Committee operates in a transparent and unbiased way, all Governance Committee Members will be requested to complete a written declaration of conflict of interest to the Chair.
The Clinical Indemnity Scheme has been engaged by the HSE to provide indemnity cover to NOCA clinical staff and its officers and the convened members of the NOCA Governance Board and its respective Audit Governance Committees of the National Office of Clinical Audit, in respect of all clinical audit conducted by NOCA, in the unlikely event that such personal may be sued in a personal injury action alleging clinical negligence arising from the proper discharge of the duties and obligations.
Responsibilities of the Governance Committee
The primary role of the Governance Committee is to monitor the quality of care provided in each Critical Care Unit as measured by the ICU Audit. In addition the Committee will advise the Lead Clinician on the operation of the Audit and will provide the link to the overall NOCA Governance Committee to report on the operation and findings of the Audit Programme. The Lead Clinician for the Audit Programme has operational responsibility for structuring and running the Audit.
(i) Ensure that appropriate national protocols are in place for control of data, in compliance with ethical and statutory requirements
(ii) Monitor the quarterly ICNARC reports to confirm that the quality of care in each Unit is achieving acceptable standards
(iii) Ensure that appropriate interventions are being undertaken if concern arises re quality of care (see below)
(iv) Address other issues relating to quality of care in ICU as appropriate, as agreed with other relevant bodies
(v) Ensure appropriate communication of the results of the Audit by a regular report to the overall NOCA Governance Board and by the publication of an Annual Report
(vi) Provide guidance on the strategic direction of the ICU Audit Programme and on any practical issues which arise in the operation of the Audit
Governance Committee response to concerns re patient safety
Should the Governance Committee become aware of poor outcomes identified by the audit process in a particular ICU, it has a duty of care to ensure that appropriate interventions are made to correct this. A guideline definition for poor outcomes is”Outcome data which vary by more than two Standard Deviations from the Mean for the benchmark group”.
The primary responsibility for responding to concerns about quality of care lies with the local governance structures in each hospital and ultimately with the CEO. However the Governance Committee has a role in ensuring problems are detected, are responded to in an appropriate way, in providing advice to the hospital if appropriate, in providing a national overview of quality and safety of care in ICU and in providing a link between the National ICU Audit and the HSE Directorate of Quality and Patient Safety.
In the first place, a response from the Governance Committee may involve an assessment of the validity of the findings of the audit. Further potential interventions include engagement with local clinicians and with local governance structures. If these preliminary measures are not appropriate or if the Committee judges they are not proving effective, an escalated response will be undertaken.
Should the ICU Audit Governance Committee become aware of poor professional performance or process that may seriously harm or cause potential serious harm to a patient; they will communicate through the relevant channels available, including the NOCA Governance Committee, the National Director of Quality and Patient Safety, the HSE and relevant governance structures to ensure immediate action is taken to ensure patient safety.
This approach is consistent with the NOCA Escalation Policy (Jan 2013)