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MINUTE of MEETING of the
Clinical Governance Committee
Board Room, Assynt House / 9 February 2010 - 8.30am
Present: Dr Vivian Shelley, Chair
Mr Quentin Cox, Non-Executive Director
Mr Ian Gibson, Non-Executive Director
Mr Ray Stewart, Non-Executive Director
Also Present: Dr Ian Bashford, Medical Director
Ms Heidi May, Nurse Director
In Attendance: Ms Lisa MacDonald, Internal Audit (item 2)
Mr Stuart Sands, Internal Audit (item 2)
Mr Derek Leslie, General Manager, Argyll & Bute CHP, by videoconference (item 6.1)
Ms Fiona Campbell, Clinical Governance Manager (item 6.1)
Ms Fiona Thomson, Lead Pharmacist, Argyll & Bute CHP (item 6.1)
Dr Michael Hall, Clinical Lead, Argyll & Bute CHP (item 6.1)
Dr John Lyon, Chair, Argyll & Bute CHP Clinical Governance Committee, by videoconference (item 6.1)
Mrs Mirian Morrison, Clinical Governance Development Manager
Mr Malcolm Smith, Chair, NHS Western Isles Clinical Governance Committee
Miss Irene Robertson, Board Committee Administrator
1 WELCOME AND APOLOGIES
The Chair welcomed Malcolm Smith, Chair, NHS Western Isles Clinical Governance Committee, and Lisa MacDonald and Stuart Sands, Internal Audit, who would be facilitating the review of the Committee’s effectiveness (item 2).
Apologies were noted from Mr Garry Coutts, Mrs Margaret Davidson, Dr Roger Gibbins, Dr Lesley Anne Smith and Dr Margaret Somerville.
2 CLINICAL GOVERNANCE COMMITTEE – PERFORMANCE REVIEW
Mr Sands set the background to the review of the Committee’s performance. A questionnaire had been sent out in advance of this meeting seeking views and comments from members and key stakeholders on the following areas of the Committee’s operation:-
· Role and remit
· Agenda
· Membership
· Groups providing assurance to the Committee
· Reporting Arrangements
· Administrative Arrangements
Discussion followed on the results of the questionnaire during which a number of areas for further work were identified to improve the Committee’s effectiveness. Mr Sands indicated that he and Ms Macdonald would prepare a full report of the discussion with an action plan setting out responsibilities for taking forward the issues identified and timescales for implementation.
The Committee:
· Agreed the areas for further work.
· Noted that Mr Sands and Ms Macdonald would prepare a report and action plan for presentation to the Committee at its next meeting.
3 EMERGING ISSUES
There were no clinical issues to report.
Dr Bashford was pleased to inform the Committee that Lesley Anne Smith had been accepted for a Quality Improvement Fellowship based with the Institute of Health Care Improvement in the USA with effect from 1 July 2010. Discussions were taking place with the Clinical Governance and Risk Management Team to agree interim arrangements for taking forward the clinical governance agenda in Dr Smith’s absence. An update on the position would be provided at the next meeting.
4 MINUTE OF MEETING HELD ON 11 NOVEMBER 2009
The minute of meeting held on 11 November 2009 was approved.
5 MATTERS ARISING
5.1 Update on items previously discussed at the Clinical Governance Committee
5.1.1 Radiological Investigation at Lorn & Isles
Dr Bashford confirmed that the incident report had been finalised. It was a comprehensive document from which a set of action points had been identified and completed. There were no significant impacts on clinical outcomes. The report would be covered in more detail as part of the presentation by the Argyll & Bute CHP representatives at item 6.1.
The Committee Noted that the report had been finalised and that a copy would be circulated to the members.
5.1.2 Pandemic Flu Update
The Committee received the circulated update. The position had stabilised and the expectation was that there would be a reduction in the number of cases in the weeks ahead. NHS Highland was in a good state of preparedness in terms of staff training and systems, and contingency plans were in place should there be a further resurgence.
The Committee Noted the current position.
5.1.3 Clinical Governance and Infection Control Structures and Reporting Arrangements
Heidi May advised that she would shortly be meeting with relevant officers to further consider structures and reporting arrangements. While the Board received a detailed report at each meeting regarding infection control issues, Ms May felt it appropriate that the Control of Infection Committee should continue to report in to the Clinical Governance Committee. A report would be submitted to the next meeting of the Committee .
5.1.3 Better Together Patient Experience Programme
Mirian Morrison reported that the inpatient questionnaire had recently been circulated. The response rate to date was 22%, a first reminder would shortly be issued. Consideration was currently being given to the next phase of the exercise and its implementation.
5.1.4 Review of Nursing, Midwifery and Allied Health Professional (NMAHP) Registrations
It was noted that a new policy regarding NMAHP registration had been developed.
5.2 Clinical Governance Committee Action Plan – Update
There was circulated updated action plan detailing the position as at 9 February 2010.
Arising from discussion at the last meeting it was agreed that the following items should be included in the plan:-
· Patient’s Diary – a presentation to be made to a future meeting
· Cervical Screening Programme – follow up on issues relating to reporting arrangements for the programme and areas of responsibility for ensuring its implementation
With regard to the record keeping audit tool, Quentin Cox advised that a medical audit tool had been developed which the Area Medical Committee had discussed at its recent meeting. The Area Medical Committee had felt the tool was rather complex and unwieldy and needed to be simplified. They had not yet considered the audit tool currently being used by nursing staff and the potential to adapt it for use by medical staff. It was recommended that an evaluation of the nursing tool should be undertaken and the findings reported to the Committee.
The report relating to the Cancer Steering Group was rescheduled to the next meeting of the Committee in May 2010.
Noting the establishment of a working group to take forward actions arising from the Scottish Confidential Audit of Severe Maternal Morbidity, Ms May recommended that this work should be brought to the attention of the Maternity Services Committee.
The Committee Noted progress to date against the action plan and the further issues identified for action.
Dr Michael Hall and Mrs Pat Tyrrell joined the meeting
6 ASSURANCE AND ACCOUNTABILITY
6.1 Clinical Governance and Risk Management within Operational Units
Presentation by Argyll and Bute CHP
The Chair welcomed Derek Leslie, General Manager, Dr John Lyon, Chair, CHP Clinical Governance Committee, Fiona Campbell, Clinical Governance Manager, and Fiona Thomson, Lead Pharmacist who had all joined the meeting by videoconference. She was also pleased to welcome Dr Michael Hall, Clinical Director, and Pat Tyrrell, Lead Nurse, who were attending the meeting in person.
Dr Lyon described the clinical governance structure and reporting arrangements within the CHP. Mrs Tyrrell then outlined activity around HAI and the infection control structures and systems in place, emphasising the importance of learning lessons and putting the knowledge thus gained into practice. In this latter regard leadership was key and ensuring staff were appropriately trained and had a clear understanding of their roles and responsibilities. Audit and monitoring were also important components of the clinical governance system. Mrs Tyrrell referred to the recommendations within the Health Facilities Scotland Report 2009, the significant learning points therein and the need to build them in to local plans for the delivery of care. The CHP was currently undertaking a review of bed spacing and hand hygiene facilities, arising from which an action plan would be developed to address priority areas. Mrs Tyrrell advised that the CHP had made substantial progress with compliance with hand hygiene.
Ms Thomson gave an overview of medicines safety activity, noting that there were well established governance and management structures in place. An action plan had been developed from the National Patient Safety Agency Reports ‘Safety in Doses’ (2007 and 2009). Implementation of the action plan would be overseen by the recently established CHP Medicines Safety Group which had also been tasked with encouraging the reporting of medication incidents via the NHS Highland Incident Reporting system. A ‘Key Lessons Bulletin’ had been developed in order to disseminate key messages from recent reported incidents reviewed by the Group. A work programme was in development, aimed at promoting and embedding a medication safety culture. Anticoagulation was a priority issue, other key areas for action included the roll out of the Scottish Patient Safety Programme Medicines Management Bundle, the development of an audit programme, and the development of Medicines Safety Champions. A potential area for consideration by the Group was medicines safety in non-NHS premises such as care homes.
Mr Leslie gave the background to the Critical Incident Review concerning the radiology reporting service in Oban. The investigation determined that there were no cases where any missed pathology had a significant and detrimental effect on patient care, management or safety. However the review had highlighted a number of areas for action, including communications with patients and professionals, and inter-professional communication between primary and secondary care. There were also issues around recruitment of locums and the need to ensure peer support for single handed practitioners. The issues highlighted had informed the review of radiology service provision in the CHP. As of April 2010 the service would be part of the NHS Highland clinical governance structure. The Medical Workforce Planning Group would be progressing certain issues. A Performance and Revalidation Group was to be established shortly for secondary care (a similar group already existed for primary care) to look at competencies and consultant performance. An action plan had been developed from the recommendations in the review report and progress with implementation would be monitored by the CHP Clinical Governance and Risk Management Group. On a point raised relating to services provided to CHP residents by other Boards and the need to be assured of governance Mr Leslie indicated that he would be interested in exploring whether the model of service agreed between NHS Highland and NHS Western Isles might inform the service level agreement which Argyll and Bute currently had with NHS Greater Glasgow and Clyde. Malcolm Smith agreed to follow up this proposal.
On behalf of the Committee the Chair thanked the Argyll and Bute Team for their comprehensive presentation.
The Committee:
· Noted the issues raised in the report and the work ongoing to further embed clinical governance in all areas of activity.
Mr Leslie, Dr Lyon, Ms Campbell and Ms Thomson left the meeting
6.2 Clinical Governance and Risk Management Performance Report
Mirian Morrison spoke to the circulated report covering the period April – December 2009. Datix, the new online incident reporting system, had been implemented at several sites and the project remained on track to achieve full implementation of the system by the target date of 31/03/10. Discussion followed on how realistic baselines might be established for the various categories of incidents, as a measure of performance against achieving a reduction in the numbers of incidents. It was noted that quarterly reports were currently issued to the operational units regarding incidents in their areas, and monthly reports would shortly be available, facilitating follow up of incidents and enabling the loop to be closed. It was proposed that an analysis of the available data be undertaken in six months’ time to determine if any trends were emerging from which it might be possible to establish a baseline.
NHS Highland was behind trajectory in respect of the implementation of the Scottish Patient Safety Programme. There were some issues around data reporting to be resolved. An action plan had been developed to assist the operational units to get performance back on track.
The Committee:
· Noted the report and the actions being taken to address the issues identified.
· Proposed that an analysis of the incident reporting data be undertaken in six months to identify any trends and inform future actions.
6.3 Clinical Governance Work Programmes 2009 – 2010
Mirian Morrison updated the Committee on progress against the Committee’s work plan, copy of which had been circulated together with an overview of the Committee’s agenda detailing core areas of work.
There was also circulated copy of the Clinical Governance and Risk Management work programme as at January 2010. Further work required to be done on patient and public involvement in clinical governance activity and gaining feedback. The Committee agreed that it would be helpful to have a presentation on this area of work at a future meeting, and which could be linked in to the planned presentation on the Patient’s Diary.
The current system for dealing with Safety Alerts, Hazard Notifications, etc was under review. It was noted that Datix, the online incident reporting system, had a Safety Broadcast Alert System which it was proposed to use to disseminate all such safety alert documents. There would be a pilot of the system during February/March 2010 to evaluate its effectiveness.
The Committee Noted the progress to date against the work programmes and the areas for further work.
6.4 Clinical Governance Forum Update
Ian Bashford reported on the meeting of the Forum held on 05/01/10, the minute of which was circulated. The Forum was still in the stages of development and it was the intention to review its remit and operation in a few months’ time.
It was agreed that the minutes of meetings of the Forum would be considered as a substantive item rather than being included in the ‘For Information’ section of the agenda.
The Committee Noted the report of the Clinical Governance Forum meeting on 05/01/10.
6.5 Clinical Governance Committee Annual Report 2009 – 2010
The Committee was required to submit its annual report for 2009/10 to the Audit Committee meeting in May 2010. In discussing the content of the report, the Committee proposed that the following topics should be included:
· The self assessment for the NHS QIS Clinical Governance and Risk Management Standards review