The quality governance framework is an excellent way of ensuring high-quality care is in place - the key is using it properly, writes Kate Hall.

Effective quality governance is essential but what do we really mean by it?

In August 2010, Monitor introduced the quality governance framework into its assessment process. All foundation trusts authorised since this date have been assessed against the framework. Trusts will only be authorised with a quality governance score of 3.5 or less; if they score four or more they will not be authorised. The framework asks a series of 10 questions, split into four main categories:


  • Does quality drive the trust’s strategy?
  • Is the board sufficiently aware of potential risks to quality?

Capabilities and culture

  • Does the board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda?
  • Does the board promote a quality-focused culture throughout the trust?

Process and structure

  • Are there clear roles and accountabilities in relation to quality governance?
  • Are there clearly defined, well understood processes for escalating and resolving issues and managing quality performance?
  • Does the board actively engage patients, staff and other key stakeholders on quality?


  • Is appropriate quality information being analysed and challenged?
  • Is the board assured of the robustness of the quality information?
  • Is quality information used effectively?

It is easy to answer “yes” to these questions at first glance but quality governance is not a tick-box exercise - it is a term used to describe how hospitals seek evidence-based assurance that they have appropriate structures, processes and a culture in place to ensure the focus is on quality.

Initial scepticism

Although it was first introduced to Monitor’s assessment process, the framework should not be viewed as something only for aspirant foundation trusts.

Last year, through the compliance framework, we asked existing foundations to “have regard” to it; this year we are asking trusts to “self-assess” against it.

In general, aspirant trusts have valued the framework, even if they had some initial scepticism, as it has helped them to identify weaker areas and raised the standard of quality governance within their organisations.

Existing foundation trusts have also benefited. An FT since April 2008, Mid Cheshire Foundation Trust is one organisation which decided to use the quality governance framework to assure the board that the systems and processes within the organisation were robust and effective.

Chief executive Tracy Bullock was conscious that the quality governance framework was something that was not part of the assessment process at the time Mid Cheshire was authorised.

As she wanted the board to be able to assure itself that its governance systems were robust and functional she introduced a process whereby all board members were able to provide an individual view of the trust’s position against the framework criteria, using an electronic voting system.

This then brought together the individual responses to provide an overarching position in respect of the trust’s quality governance arrangements.

The board was first introduced to the framework at a board away day in December 2010 as part of a development programme, although at this stage the scoring mechanism had not been developed. However, this was considered a useful exercise and once published the board formally completed the self-assessment in July 2011.

The board found the results of this assessment disappointing with a score of 4.5, being conscious that trusts with a score of over 3.5 are not authorised. The key finding was lack of evidence and while members of the board considered their processes and structures robust they found insufficient evidence to confirm this. Ms Bullock admits that they were quite hard on themselves, but felt it was important to use the framework as an opportunity to make real improvements.

Evidence of quality impact assessment on cost improvement schemes was one area that needed strengthening. Anecdotally the board felt that it did consider the impact on quality when planning, developing and delivering CIPs but there was little or no audit trail or evidence to substantiate this. As a result of the assessment a clear documented process is now in place which is open, transparent and monitored throughout the delivery of the CIP.

Since its initial assessment the board committed to six-monthly reassessments, the last one being undertaken in December 2011, which resulted in a score of 0.5. This provided the board with significant assurance that the action plan put in place had gone a long way towards addressing the gaps identified.

Ms Bullock is clear that going through the framework in detail provided them with a clear focus and solid information regarding where they needed to concentrate improvement efforts.

Making the changes has improved quality governance and performance and means they have a level of assurance that they did not have at the outset.

Minding the gaps

Through experience we know the variation in approach to quality governance in hospitals is significant. The drive and willingness of boards to improve quality governance and efficiency in hospitals, the strength of systems and structures and the culture between trusts are all-important factors.

Some trusts might look through the quality governance framework and feel that everything is in place and that they have sufficient assurance, but very few will really be in this position.

For aspirant trusts the self-assessment score is universally better than the score that we subsequently give after reviewing the evidence.

FTs authorised before August 2010 will not have gone through this process, but self assessing against the framework can only be beneficial. Some trusts might get more of a shock than others, particularly the longer-standing FTs, but, like Mid Cheshire, if you know where the gaps are these can be addressed proactively.

Look at the 10 questions and when you have been through them once answering yes, go through them again. Quality governance is not a tick-box exercise, it is not simply part of Monitor’s assessment or compliance function, it is a way of improving and ensuring quality services within organisations.

Quantifying quality

We know that effective quality governance is essential but what do we really mean by it? Monitor’s definition of quality governance is “the combination of structures and processes at and below board level to lead on trust-wide quality performance (safety, clinical effectiveness and patient experience) including:

  • ensuring required standards are achieved
  • investigating and taking action on sub-standard performance
  • driving continuous improvement
  • identifying, sharing and ensuring delivery of best-practice
  • identifying and managing risks to quality of care”.

Source: Monitor

Kate Hall is a policy adviser at Monitor.

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