Staff survey results indicate improvement in staff governance across NHS Scotland

NHS Scotland is unique in that it meets special standards relating to ’staff governance.’

Staff governance is a system of corporate accountability for the fair and effective management of staff. It focuses on how NHSScotland staff are managed and feel they are being managed, which with Financial and Clinical Governance completes the Governance framework within which NHS Boards, Special Health Boards and NHS National Services Scotland must operate.

A key indicator of staff governance is the biannual national staff survey. The results from the staff survey are used to develop action plans that facilitate delivery against the Staff Governance Standard.

Over 58,000 (37%) employees from all NHS Boards and Special NHS Boards across Scotland responded to the national survey which was sent out in October and November 2008.

The staff survey, which is carried out every two years, focuses on how staff are managed and feel they are managed and invites employees to share their views and experiences of working for the NHS.

The national results for 2008 show that the majority of respondees:

- were happy to go the ‘extra mile’ at work when required;
- were satisfied with the support they receive from work colleagues;
- felt their job makes good use of their skills and abilities;
- were clear about what they were expected to achieve and have the information to they need to do their job well; and
- intend to still be working within their NHS Board in 12 months time.

Compared to the last survey in 2006, the findings show improvement in a number of areas:

- 17% more respondees feel they have equality of opportunity in the work place;
- 16% more respondees feel satisfied with the opportunities they have to put forward new ideas or suggestions for improvement;
- 16% more respondees are confident their ideas or suggestions would be listened to;
- 12% more respondees feel that NHS Scotland is a good place to work;
- 10% fewer respondees stated they have experienced a violent incident in the last 12 months.

Both the staff survey results and the Staff Governance Standard can be accessed here.

NHS fire and risk assessment officer fined for fraud

Accirding to the Manchester Evening News (30 January 2009), an NHS fire and risk assessment officer has been sacked and ordered to pay out more than £5,000 after falsely claiming travel expenses.

Mark Ashton cheated East Cheshire NHS Trust out of more than £1,000 by claiming mileage for made-up journeys.

Ashton, 50, of London Road South, Poynton, who had worked as a fire and risk assessment officer for the trust since 2001, admitted fraud by false representation at Macclesfield magistrates court.

He was given a 12-month conditional discharge and ordered to pay back £1,181 in compensation and more than £4,000 in costs.

For further information, click here.

A governance framework for differentiating between research, audit and service review activities

Some readers may be interested in a paper from a 2007 issue of Clinician in Management (now the International Journal of Clinical Leadership) that describes a practical governance framework that attempts to ensure that obstacles are not put in the way of progressing with innovative clinical quality improvement projects.

With the advent of evidence-based practice and the need to demonstrate the effectiveness and efficiency of service provision, healthcare practitioners find themselves having to comply with increasingly complex governance requirements surrounding the collection of data within an NHS organisation. A number of authors have suggested that the administrative burden that accompanies clinical effectiveness activities could in itself stifle innovations in practice. Putting obstacles in the way of ‘quality improvement’ projects could lead to poor practice and a potential reduction in the much needed service developments. This anxiety has to be balanced by the need to fully comply with research governance processes and ensure ethical considerations apply to both research activities and service evaluations.

Debate exists about the differentiation between such activities, whether the activity is research requiring full governance, audit or service development improvement projects. This paper describes the work undertaken at Sheffield Teaching Hospitals NHS Foundation Trust to develop a framework for classification of data collection activities, by using ’simple rules’ and subsequent ‘rule in questions’. The paper discusses how this framework ensures that appropriate ethical considerations take place for all activities and how an NHS organisation can reduce the risk of contravening research governance and local clinical governance requirements whilst still encouraging quality improvement projects.

The full paper can be purchased here.

View presentations from HSJ conference ‘Intelligent information for effective governance’

The Health Service Journal conference Intelligent information for effective governance, held on 22 January 2009 in London, attracted around 170 people and was a great success.

Speaker presentations are now available for viewing by clicking here.

Clinical Governance Conference – University of Hertfordshire, 12/13 March 2009

It’s good to know that in this era of ‘Darzification’, clinical governance, which was/is all about improving quality in the NHS, is alive and kicking!

This one and a half day conference, Clinical Governance – Where are we now? Where do we want to go?,will explore current issues, impacts on the delivery of quality healthcare and challenges arising from the Darzi report.

Speakers include representatives of the National Patient Safety Agency and National Institute for Health and Clinical Excellence.

The conference will be held at University of Hertfordshire, College Lane Campus, Herts, AL10 9AB, and will run from 09.00-16.00 on Thursday and 09.00-13.00 on Friday. It costs £100 and CPD certificates will be provided.

Further information can be obtained from Karen Wells – k.c.wells@herts.ac.uk (tel. 01707 286393) or Tristan Brice – t.brice@herts.ac.uk (tel. 01707 286108).

One way to govern – a short Policy Governance article by Caroline Oliver

Caroline Oliver, international board governance specialist and author of three books on John Carver’s Policy Governance model, has recently published a short article on Policy Governance.

The article begins with Caroline saying that “Successful governance provides a mechanism for people to direct and control the organisations we create to make the differences we desire and thereby take our societies forward. Whether we are talking about national governments, public organisations, for-profit organisations or non-profit organisations – governance is what makes their wheels go round.”

Read the rest of Caroline’s article here.

NHS Governance 2009 – A three day event organised by the Health Service Journal

The Health Service Journal (HSJ) is presenting its 5th annual governance conference as a three day event in London on 23-25 June 2009.

Day 1 (23 June) will look at ‘Transformational NHS Governance – Developing robust, flexible and fit-for-purpose governance systems to support whole system change.’

Day 2 (24 June) will look at ‘Board Level Development – Cultivating the skills to strengthen governance systems from board to ward and beyond.’

Day 3 will look at ‘PCT Governance – Developing sound governance for commissioning arms, provider services and the body corporate.’

Full details about the event will appear in due course and can be found here.

In the meantime, please ensure the event is in your diary.

Fundamentals of NHS governance – forthcoming one day Health Service Journal event

Watch out for a forthcoming one day event in Birmingham covering the fundamentals of NHS governance organised by the Health Service Journal (HSJ).

Healthcare Governance Review has seen a draft of the programme for the event, which includes:

- The Care Quality Commission and regulation
- Quality assurance
- Clinical, corporate and information governance
- Integrated governance
- Board level development
- PCT governance
- Foundation trust governance
- Governance between Organisations

Speakers will include:

- Professor Paul Stanton, Northumbria University
- Dr Jay Bevington, Deloitte
- John Wilson, NED, East Riding and Yorkshire PCT
- Stuart Emslie, editor, Healthcare Governance Review

Further information, when it becomes available, can be found here.

Government publishes NHS constitution for England and statement of NHS accountability

The NHS Constitution was published on 21 January 2009. It was one of a number of recommendations in Lord Darzi’s report ‘High Quality Care for All’ which was published on the 60th anniversary of the NHS and set out a ten-year plan to provide the highest quality of care and service for patients in England.

The Constitution commits the Government to providing a statement of NHS accountability. This document accompanies the NHS Constitution and provides a summary of the structure and functions of the NHS.

Both the NHS Constitution and the statement of NHS accountability are key documents relating to the governance of the NHS in England.

According to the government, “The NHS belongs to us all. The NHS Constitution brings together in one place for the first time in the history of the NHS, what staff, patients and public can expect from the NHS.

As well as capturing the purpose, principles and values of the NHS, the Constitution brings together a number of rights, pledges and responsibilities for staff and patients alike. These rights and responsibilities are the result of extensive discussions and consultations with staff, patients and public and it reflects what matters to them.

Subject to Parliamentary approval, all NHS bodies, and private and third-sector providers supplying NHS services in England will be required by law to take account of the Constitution in their decisions and actions. The Government will have a legal duty to renew the Constitution every 10 years. No Government will be able to change the Constitution, without the full involvement of staff, patients and the public.”

Download the NHS constitution and statement of NHS accountability, along with other documentation, here.

In the USA, hospital boards are leading the way on quality and patient safety

As part of the recently completed 5 million lives patient safety campaign by the Institute for Healthcare Improvement (IHI) in the USA, more than 2100 boards of over 4000 participating hospitals signed up for the “Boards on Board” intervention. In doing so, they were publicly embracing their responsibility for improving quality and patient safety.

Joe McCannon and James Conway from the IHI have written an article titles A new era for leadership of quality and safety in www.modernhealthcare.com

They say that as a result of the commitment demonstrated by boards, IHI and their partners working on healthcare governance were flooded with requests from board members for content, information, ideas, and help. And board members made great personal investments of time and talent. Thousands of trustees and executives went to the classroom, studied hard, and demonstrated relentless resolve. (After one recent nine-hour training session with nearly 200 board members and other executive leaders, more than half of those attending remained afterward for further discussion. They continued at their tables, with their teams, solving problems for patients and staff.)

Hospital boards and executive teams took on this challenge, when it has not been their traditional role practice, because they believed they must. Patients deserve it, standards-makers and regulators increasingly expect it, and they know medical errors can undermine the best-laid business plan. But, for the most progressive boards, a strong commitment to safety and quality also creates significant opportunities-for better patient outcomes, for managing costs (particularly with new Medicare reimbursement incentives), for gaining local market share, and particularly for bringing energy to professionals and staff who can reconnect to their own care-giving vocation.

Alongside executive leaders, the most progressive boards set clear organization-wide aims for quality that are transparent and that translate into clear action for every leader, clinician and staff member in the facility. Quality appears as the first agenda item in every meeting of the board and management. Quality meetings-once held quarterly, if at all-are now held monthly with a clear focus and priorities. Leaders are getting out on the floors, interviewing patients, families, and staff. They are observing barriers to progress and removing them. Expectations change, and a culture of quality and safety follows suit.

Further, McCannon and Conway cite promising examples of boards leading the way on quality and patient safety such as:

- At the Henry Ford Health System in Detroit, Mich., the board and executive leaders set a goal to reduce hospital mortality by 25% over three years, and they achieved it. With the board and leadership together at every step, they created the will, brought together the ideas and the plan, and then assured relentless execution.

- At the 159-bed Delnor-Community Hospital in Geneva, Ill., a “patient experience” story has been presented at board meetings since January 2006. Each story is specifically selected and connected to highlight a “Big Dot” or “Driver” measure on the Clinical Dashboard (i.e., “connecting the dots”). The story is told by a patient, a medical staff member and/or senior management, at the start of the meeting and usually lasts about 30 minutes.

- At one of the largest healthcare systems in the world, the New York Health and Hospitals Corporation, the board has set the goal of being the safest public hospital system by 2010 and has gone fully transparent on their key measures for every hospital.

According to McCannon and Conway, most of the hospitals that have adopted the “Boards on Board” intervention have not yet demonstrated this level of commitment, but a new trend is apparent. And, as a result of the 5 Million Lives Campaign and complementary governance initiatives, a permanent national learning network is now in place to help hospitals learn from and mentor one another on trustee accountability and additional important improvements.

 ”This mobilization could not be more timely. Tense external pressures-terribly difficult economic constraints chief among them-can distract organizations if their leaders lose resolve or fail to see quality as a force for organizational progress and prosperity. Instead they must make sense of competing demands, and give everyone in their facilities a sense of purpose.

“Hospital boards in the USA are now engaged as never before, and, more than ever, there is a belief that they need to lead the way.”

Read McCannon and Conway’s article here (free registration required).

Notable quote: Active boards….

“Just asking questions is passive. Active boards lead by setting comprehensive standards for the organisation and constantly monitoring against those standards – asking ‘where are we up to?’ on each and every one.”

Caroline Oliver (click here)

Religion or belief – The latest DH governance ‘muddle’

The Department of Health in England (DH) has published Religion or belief – A practical guide for the NHS.

In most respects it looks like a very good document. It is part of a suite of equality guides and gives practical advice to NHS organisations to help them comply with recent equality legislation, understand the role of religion or belief in the context of healthcare, and integrate this knowledge into single equality schemes (SESs).

Characteristically, the DH has, however, got itself into a muddle over governance issues. The guidance states in Worksheet 1 (pages 44-47) that a trust board member should be identified as “responsible for religion or belief issues”; that trust boards should agree action plans in relation to religion or belief’ and boards should monitor religion or belief matters.

Board level monitoring is fine, but the notion of holding a board member responsible for religion or belief, or the board ‘rubber stamping’ management’s action plans in respect of same, does considerable damage to the cause of good governance. Trust boards should be governing bodies, not management entities. Governance and management are two very different concepts and the DH appears to be stuck in the days when trust boards were introduced as management boards. Times have changed and Healthcare Governance Reviewbelieves that the DH needs to get its act together around governance issues for the benefit of the NHS.

Download the DH publication Religion or belief – A practical guide for the NHS here.

New book for boards – Getting Started with Policy Governance

Caroline Oliver, author and co-author of a number of books on Policy Governance, has a new book that EVERYONE concerned with board governance in healthcare should read.

Getting Started with Policy Governance – Bringing Purpose, Integrity, and Efficiency to Your Board is, according to Geraldine Peacock, former chair of The Charity Commission,  “…..a great read…..comprehensive, accessible, and fills a big gap in the market.”

Policy Governance was developed by Dr John Carver, whose seminal book for public and non-profit organisations - Boards That Make a Difference – is by the far the World’s largest selling book on board governance, with over 100,000 copies sold.

Carver’s Policy Governance approach was commended in the Department of Health’s recent publication on Implementing Trust, Assurance and Safety (click here for further information) as providing “….the most relevant and sensible advice, focussed on the public/not for profit sector, and widely respected.”

Dr Jay Bevington of Deloitte’s (formerly associate director of board development at the National Clinical Governance Support Team) says “What a truly outstanding and thought-provoking book! It changed how I work with boards overnight and forever! If we all took the advice within the pages of this book, then organisations would deliver greater value to their owners and be better places to work.”

John Bruce, chair of Southend University Hospital NHS foundation trust says “For boards wanting to raise their game, this book is very thought-provoking and helpful. It’s a must for all board members. Board chairs – ignore it at your peril!”

Caroline’s book is currently priced at £15.83 on amazon.co.uk and can be found here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is CEO of the UK Policy Governance Association, a non-profit organisation dedicated to advancing owner-accountable, ethical and effective governance using the Carver Policy Governance model.

‘Substantial improvement’ in infection control at Maidstone and Tunbridge Wells NHS trust

The Healthcare Commission has found substantial improvements in infection control at Maidstone and Tunbridge Wells NHS Trust since an investigation by the watchdog in 2007 identified serious failings.

An estimated 90 people definitely or probably died as a result of Clostridium difficile, during two outbreaks of the infection at the trust in 2005 and 2006. It is estimated that a further 30 patients definitely or probably died of C. difficile between April 2004 and September 2005.

Immediately following its investigation, the Commission called for a range of changes to the way the trust cares for patients with infections and to its wider systems of prevention and control.

The Commission has now published a follow-up report detailing the trust’s progress in implementing the recommendations. It also published a report outlining findings from a routine spotcheck made in October 2008 to assess compliance with the hygiene code.

The Commission says the trust has made “huge strides” putting considerable effort and resource into improving infection control. It commends the trust for reporting its lowest rate of C. difficile infection in three years, for the period January to March 2008.

However the Commission has highlighted some areas that still require further work such as recruiting more nursing staff and learning from complaints and incidents.

The spotcheck in October found a number of breaches of the hygiene code. The most serious breach related to decontamination of equipment in the endoscopy unit. This had been addressed by the time the Commission made its final investigation follow-up visit to the trust in November.

Key improvements identified in the investigation follow-up report include:

- A re-structured board with new non-executive directors and many new directors. This new structure has clear lines of reporting and processes for escalating issues up to the board. Infection control is a consistent item at the top of the board’s agenda.
- New clinical governance and risk reporting structures which allow the trust to address key risks. A new head of governance and quality has been appointed who has revised the governance committee structure, creating four clinical governance directorates within the trust.
- Increased leadership, size and effectiveness of the infection control team led by a new director of infection prevention and control. There are two additional senior infection control nurses and a new microbiologist.
C. difficile is now recognised as a serious diagnosis in its own right, and a ‘care pathway’ has been designed and implemented for patients with the infection, ensuring they receive timely and appropriate care.
- Specific wards have been allocated for the isolation of infected patients.
- Better standards of cleaning and improvements to the hospital environment. Extra cleaning staff have been appointed, new audit systems implemented, and nurses find urgent cleaning needs are more rapidly addressed.
- The removal of beds and the installation of new wash basins to ensure appropriate spacing between beds and improved levels of cleanliness.
- An ongoing process for infection control training has been implemented, including areas such as hand hygiene techniques and sharps handling. The infection control team also runs an extensive training programme for other members of staff.

Areas requiring further work include:

- The recruitment of further nursing staff and continued work to ensure good basic nursing care.
Improvements to how the trust learns from complaints, incidents and serious untoward incidents (SUIs). The system for responding to complaints also needs to be reviewed.
- The trust is currently in the process of appointing a new medical director to the board. It must ensure this happens as soon as possible.
- The trust must embed the new clinical governance structure in day-to-day practice, ensuring that staff at all levels understand and follow the new ways of reviewing clinical care.

 For further information, click here.

See also related Healthcare Governance Review posts here, here, here, and here.

NHS Code of Practice on Records Management updated

The two-part Records management: NHS code of practice is a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice.

The code provides a key component of information governance arrangements for the NHS. This is an evolving document because standards and practice covered by the code will change over time and will be subject to regular review and updated as necessary. As a result of a review, part 2 only of the code in relation to the retention schedules has been updated in light of guidance and advice given from the NHS and professional best practice. The updated part 2 was published on 8 January 2009.

The guidelines contained in this code of practice apply to NHS records of all types (including records of NHS patients treated on behalf of the NHS in the private healthcare sector) regardless of the media on which they are held.

Download the new Part 2 and all other relevant records management documentation on the DH website here.

Guidance on ‘Never Events’ to be published

The NHS Operating Framework for 2009/10 identified the implementation of ‘Never Events’ as a key priority for the NHS in England. Never Events are, quite simply, events that should never happen. Never Events have been a common feature of patient safety in other countries for several years now, and the NHS appears to be slowly catching up!

The NHS Operating Framework  suggests that Primary Care Trusts (PCTs) may wish to use the list of ‘Never Events’ as part of their contract agreements with providers. During 2009/10, implementation will mainly focus on promoting clear reporting and management systems for never events. This will inform the work we undertake with the NHS to propose link to payment regimes from 2010/11 onwards. PCTs will monitor the occurrence of never events, within the services they commission, and report these to the National Patient Safety Agency (NPSA) and publicly report them as part of their annual reporting on quality and safety.

Strategic Health Authorities (SHAs) will support PCTs and providers by providing advice on root cause analysis of Never Events, should they occur. The NPSA will, apparently,  provide web resources and publish an annual report on never events, disseminating the lessons learned.

The NPSA will, apparently, publish guidance for PCTs on implementing Never Events in late January 2009. The NPSA’s list of Never Events is:

• Wrong site surgery
• Retained instrument post-operation
• Wrong route administration of chemotherapy
• Misplaced naso or orogastric tube not detected prior to use
• Inpatient suicide using non-collapsible rails or whilst on one-to-one observations
• Absconding of transferred prisoners from medium or high secure mental health services
• In-hospital maternal death from post-partum haemorrhage after elective Caesarean Section
• IV administration of misselected concentrated potassium chloride

For further information, visit the NPSA website here.

NHS Primary Care Trust director jailed for CV lies

According to www.publicservice.co.uk (the information portal for the public sector, 7 January 2009) Stoke-on-Trent Primary Care Trust (PCT), now NHS Stoke-on-Trent, made Lee Whitehead its new director of planning and modernisation but had to sack him when they found out that he had lied on his curriculum vitae (CV) about having a Master’s degree and a doctorate. Not only did Whitehead lose his £78,000-a-year job, but he has also been sent to prison for 12 weeks after the Department of Work and Pensions decided to take the matter to court.

According to a report in the Stoke-on-Trent Sentinel newspaper, Whitehead said in November 2006 that he had a first class science degree, a post-graduate science degree, a PhD in psychology, and that he was a member of the British Psychological Society. The only truthful statement was that he had a science degree but it was second class. The irony is that none of these made up qualifications were needed for him to get the job.

Paul Kay, prosecuting for the DWP, said: “The post-holder was not required to hold either a Master’s or a PhD, or be a member of the BPS. But clearly these assisted him in getting the job.”

It wasn’t any checks made by the PCT that brought Whitehead’s lies to light but another member of staff who was suspicious about his qualifications. When the PCT then challenged Whitehead he failed to provide any proof and the bodies he said he studied at and was a member of had no record of him. The court heard Whitehead had told the same lies to get his previous job with another PCT.

A spokesman for NHS Stoke-on-Trent said their selection procedures had been tightened up, adding: “We weren’t the first organisation Mr Whitehead made his irresponsible claims to. People can be assured that we have strict checks in place to ensure that all our staff are qualified to do their jobs.”

Insights into the human and financial cost of ‘hospital blunders’

There are three noteworthy stories in the Daily Mail today (7 January 2009).

The first tells of the tragic death of a 5 year old girl at Oxford Radcliffe Infirmary caused, according to the newspaper, by ‘gung ho surgery by a trainee.’ Her father died 11 months later of a heart attack, which her mother puts down to the stress of dealing with his daughter’s death and the hospital ‘not living up to its responsibilities.’ The hospital says it has “learnt from the tragedy and put [the] lessons into practice.” Read the full story here.

The second story tells us that ‘Surgeons who leave operating equipment inside patients cost NHS £9m.’ Patients who leave operating theatres with surgical equipment accidentally left inside them are being awarded millions of pounds in compensation. Apparently, according to the article, around “two people a week find surgeons have left behind foreign objects such as surgical swabs, clips and screws, according to Government figures released after a Freedom of Information request. And with the average victim pocketing £17,900, the mistakes have cost the NHS a total of £9million over the past five years, with payouts made to more than 550 patients.” Read the full story here.

The third is, perhaps, less noteworthy as it is obviously a politically motivated story from the Liberal Democrat Party. According to the headline, ‘Deaths from hospital blunders soar 60% in two years as NHS staff ‘abandon quality of care to chase targets’ – read the full story here.

Healthcare Commission issues improvement notice over system failings relating to infection control

The Healthcare Commission has issued an improvement notice to Homerton University Hospitals NHS Foundation Trust, requiring urgent attention to its infection control systems.

While the trust’s rates of MRSA bloodstream infection and Clostridium difficile have generally been low, the Commission found significant breaches of the hygiene code during an unannounced inspection.

The inspection at Homerton University Hospital identified breaches of the Government’s hygiene code that gave inspectors cause for concern. These included arrangements for the decontamination of equipment, concern about adequacy of mandatory staff training, and lack of follow up to internal audits. There were also issues about reporting of information to the board to enable them to assure themselves that systems for preventing infection are in place and working in practice.

According to the Healthcare Commission “All trusts must drive rates of infection as low as they possibly can and to do this they must have all the necessary systems in place to deal with infection prevention and control. This is extremely important for patients. Relatively low infection rates are not enough; systems need to be in place to keep infection to a minimum.”

For further information, including a detailed analysis of the issues giving cause for concern and their link to relevant duties set out in the Government’s hygiene code, click here.

ACCA guidance for directors on resigning from a board

The Association of Certified Chartered Accountants (ACCA) has published an interesting 24 page guidance document for directors on resigning from a board. Whilst written for directors of UK listed companies, ACCA believes the guide will be useful to members and potential members of other governing bodies in the public and not-for-profit sector, including the NHS.

The guide might be of particular interest to existing and prospective NHS foundation trust board members – both executive and non-executive.

If you are an existing NHS board member you might like to consider the following non-exhaustive list of possible resignation issues presented in the guide. Could any of these apply in your situation? If so, you should download and read a copy of the ACCA guide.

1. Are you sure that the board has taken a fundamental decision with long-term impact, perhaps on long-term strategy, that you are convinced is wrong and that you will not be able to support going forward?
2. Can you see clearly that the company is embarked upon a policy that will lead to a future crisis and from which you have been unsuccessful in persuading the company to pull back?
3. Is the board acting dishonourably by supporting, or conniving in, a significant course of action in breach of:
• covenants entered into with a third party (without
sufficient restitution)?
• the duties of directors?
• the law?
4. Is there a breakdown of trust and confidence between members of the board which has proved impossible to resolve, but which your resignation is the best way to resolve?
5. Has the board rejected the advice of a committee of the board on a significant matter that the committee considers it cannot compromise over; and have all means to resolve the disagreement been exhausted?
6. Is it apparent that you are unable to make an effective contribution as a director?
7. Do you have irresolvable concerns about disclosure and financial reporting to the extent that you consider published results to be misleading?
8. Have you failed to obtain action to align the financial interests of top management with the interests of the company’s members?
9. Have you failed to persuade the board to address your significant concerns about the quality of the company’s corporate governance?
10. Have you lost confidence in the integrity of colleagues on the board, with no real potential of being able to address this successfully?
11. Have you lost confidence in the competence or integrity of non-board management, for actions that you as a director will be held responsible, but which you as a director have been unable to resolve?

 Download the ACCA guide Resigning from a board: Guidance for directors here.