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#1 Posted : 02 August 2018 10:39:24(UTC)
Claire Bale

Rank: Administration

Groups: Moderator, Administrators
Joined: 30/08/2013(UTC)
Posts: 42


1. Purpose
The Clinical Benchmarking Group (CBG) will to oversee the interrogation and analysis of clinical benchmarking data to identify variance and alert the Executive Team, through the Chief Medical Officer (CMO) or Senior Leadership Team, where District Health Board (DHB) performance is sub-optimal

2. Accountability Terms of Reference
a. The CBG will be a formal group of the Clinical Governance Group/Committee
b. The Chair of the CGB will be designated by the CMO or Chief Executive Officer (CEO)

3. Work of the Group
a. To review clinical benchmarking data from different sources available to the DHB to identify variance and analyse implications
b. To establish and develop “early warning systems” which, on a specialty by specialty basis, and at individual consultant level, highlight areas of potential clinical risk
c. To ensure robust feedback both to the specialities/divisions and Clinical Governance Group/ Committee, to give assurance about performance and to allow swift action to be taken
d. To validate reliability of data and reports and prevent DHB reputational damage
e. To draw to the attention of the CEO, via the Chair, any issues requiring executive action

4. Membership

Chair (Designated by CMO or CEO)
Deputy Chair (Designated by Chair)
Speciality/Divisional Representatives
Manager Clinical Coding/Assistant Manager Clinical Coding
Senior Nurse
Health Informatics Lead/Manager
Clinical Heads/Directors [representative specialities/divisions]

5. Meeting frequency and attendance
a. CBG will meet monthly, at least 8 times annually
b. CBG members must attend at least 50% of meetings in a 12-
month period (6 of 12 planned meetings) to maintain membership
c. Membership will be reviewed annually, within one month of formation
d. The Group will be considered quorate with 2 clinical members and 2 non-clinical members present (including the Chair)
e. Members can delegate attendance to meetings to a nominated individual with the appropriate level of delegated authority

6. Delegated Powers
The CBG will have the delegated authority to access all clinical information needed to perform effectively. They are not a policy making group. They will have the authority to request any

individual in the DHB to attend the CBG Meetings and produce a report if deemed appropriate. Where necessary they may request audits of clinical practice to be carried out

7. Activities
Following review of monthly reporting and identification of any outlying activity:
a. Initial Review: A member of the CBG (independent from the specialty under review) reviews the relevant cases to establish the basis to the alert. The reviews are on an audit basis and as appropriate may compare to national standards
• Escalate to Clinical Head/Lead as appropriate
• Reports are presented back to the group within 1 month to establish if further action is required
• Actions may relate to system issues or clinical practice; the latter is escalated to the CMO for consideration
b. Escalation to CMO: Following initial audit and feedback, areas requiring escalation will be forwarded to the CMO to ‘agree concern’. Further review will be formalised in accordance with any internal procedures for handling investigations into clinical practice, and/or The Association of Salaried Medical Specialists Clause 42 ‘Investigations of Clinical Practice’. The case manager and investigator allocated will be required to report back to CBG
c. Document distribution:
a) Minutes from the meetings, including supporting papers, are circulated to CBG members and other parties nominated by the Chair
b) CRAB Surgical and CRAB Medical reports are circulated to CBG members, including any requested extractions for deeper analysis and outlying activity (and alerts).
c) CRAB CBG to determine report circulation to relevant clinical leads, Governance groups, Boards and other relevant parties
9 Review
The CBG will undertake a review of its Terms of Reference annually, within one month of its formation date
File Attachment(s):
C-Ci_IG_CBGGuide_2018_07_24_v.1.1.pdf (216kb) downloaded 22 time(s).
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