APPROVED

Minute of Meeting of the NHS Grampian Clinical Governance Committee

held on Friday 12thNovember 2010 at 9.30am

in the Conference Room, Summerfield House, Eday Road, Aberdeen

Present: / Mr C Muir, Non-Executive Board Member (Chairman)
Mr T Mackie, Non-Executive Board Member
Mr M Scott, Non-Executive Board Member
In Attendance: / Dr J Callender, Clinical Governance Lead-Mental Health Services
Dr S Cole, Clinical Governance Lead, Moray CHP
Dr D Cameron, Chairman, NHS Grampian
Dr R Dijkhuizen, Medical Director
Dr J Fitton, Clinical Governance Lead - Aberdeenshire
Mrs P Harrison, Interim Infection Control Manager
Ms S Healy, Chair, Medication Safety Committee/Principal Pharmacist ARI (Agenda item 4.3)
Dr T Humphrey, Consultant Midwife (Agenda item 4.2)
Mrs B Lurie, Team Leader/Clinical Effectiveness Facilitator (Agenda item 4.4)
Professor A MacLeod, Director of Research & Development (Agenda item 4.1)
Dr D McLeod, Unit Clinical Directorand Dr Kathleen Ferguson, Consultant Anaesthetist (Agenda Item 8.2)
Mrs L Oldroyd, Nurse Consultant Patient Safety & Experience and Feedback Manager(Agenda Item 10.1 )
Mr A Pilkington, General Manager,
Ms H Robbins, Head of Clinical Governance & Risk Management
Dr E Robertson, Clinical Governance Lead – Acute Sector
Mr V Shields, Interim General Manager– Acute Sector
Mrs E Smith, Director ofNursing & Quality
Mr C Stewart, Clinical Governance Lead – Aberdeen City CHP
Mrs E Tait, Team Leader/Clinical Governance Co-ordinator
Mrs N Urquhart, Public Representative
Dr D Webster, Consultant in Public Health Medicine (representative from Public Health)
Mrs F Shepherd (Committee Secretary)

The Chairman informed the Committee that Ms J Warner, Director of Patient Safety and Performance Assessment for NHS QIS was not attending the meeting today, as scheduled but will attend a Committee meeting early next year.

The Chairman thanked Dr Gatenby who was standing down as Clinical Governance Lead for Aberdeenshire. The Chairman thanked Dr Gatenby for his contribution to the Clinical Governance Committee over the years. The Chairman then welcomed the new Clinical Governance Lead for Aberdeenshire, Dr Fitton to the Committee.

The Chairman welcomed Dr Cole to his first Committee meeting and welcomed back Dr Robertson who had returned from sick leave.

The Chairman Informed the Committee that it was agreed to defer agenda item 8.3; Grampian Nutritional Care Group Report to the next meeting in February 2011.

Item
/
Action
  1. 1
/ APOLOGIES
Apologies were received from:
Mr L Bell, Mr R Carey, Professor N Haites, Mr A Jackson,Professor V Maehle and
Dr L Wilkie.
MINUTE OF MEETING HELD ON 27th August 2010
TheMinute of the meeting held on 27th August 2010was accepted as an accurate record subject to the below amendment:
Item 5.3.2 on page 5 to include; Datix was available in the Acute Sector.
  1. 1
/ MATTERS ARISING
3.1 / Named Doctor – Cover arrangements in Moray for Child Protection
Mr Pilkington was asked to provide the Committee with an update on the cover arrangements in Moray for child protection. This item was raised at the August meeting following which there wereconcerns around the doctor for child protection in Moray leaving and the post being vacant from September 2010. The Committee asked to receive assurance and requested that senior managers take action to address this area of urgent concern.
Mr Pilkington referred to his paper and updated the Committee on actions undertaken within the Service to ensure all efforts were being addressed to secure a replacement and outlining interim arrangements.
The Committee noted the report and agreed the recommendations. They were assured appropriate action was being taken and interim arrangements to meet the demands of the Service were in place around Child Protection within Moray CHP. The Committee asked to receive regular updates on this item.
The Committee agreed to report this item to the Board. / AP
3.2 / Update on major incident plan for Royal Aberdeen Children’s Hospital
This item was raised at the previous meeting in August 2010 and clarification was sought around the new area of concern in the sector report; no major incident plan for Royal Aberdeen Children’s Hospital. Mr Pilkington informed the group that a nurse had been seconded to lead the development of the major incident plan for RACH to link with the plans in the CHP and Acute Sector work.
This item was also included in the RACH Sector report.
NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE DEVELOPMENT
4.1 / Research & Development Annual Report - 2010
The Chairman welcomed Professor MacLeod, Director of Research & Development to present to the Committee the Research & Development Annual Report.
Professor MacLeod referred to the Annual Report and highlighted the key points throughout:
  • What the responsibilities of the R&D office include.
  • Research supported by endowment funds.
  • Commercial research.
  • What the next steps were for 2011
Professor MacLeodhighlighted that NHS Grampian and the University of Aberdeen were currently the only large NHS Board and Academic Institution in Scotland who had not been inspected by The Medicines and Healthcare products Regulatory Agency (MHRA). Although there had been no contact from MHRA, preparatory work for the inspection had commenced, a joint MHRA Inspection Internal Working Group and Clinical Research Steering Group had been formed in order to guide the organisations towards compliance with the national and international standards for regulations.
Dr Dijkhuizen asked if contact had been made with other Board areas that had been inspected in preparation for our inspection. Professor MacLeod advised that the feedback received from the inspections in Dundee and Glasgowindicated that although there were some major issues there were no critical issues. Professor MacLeod informed the Committee that Ms Sime, Quality Assurance Manager had visited all areas that had been inspected and was pulling together a dossier of issues in preparation for our inspection.
Dr Dijkhuizen made the suggestion of using the Datix system to report any adverse events to assure systems were in place. Professor MacLeod commented on the benefits of tracking patients on trials, andwith pharmacological reporting adverse events. This link with Datix was on-going work.
A question was raised; how research proposals were evaluated. Professor MacLeod responded that research grants funded, go through a peer review process undertaken on behalf of NHS Grampian. With other bodies we have to ensure that they have peer review processes and even proposals funded from the Chief Scientist Office were checked that they had been peer reviewed
It was noted that there were close working relationship with the University of Aberdeen and it was asked if there were any links with the RobertGordonUniversity. Professor MacLeod mentioned that there were links with RGU but they have stronger links with the University of Aberdeen.
The Committee noted the first Annual Report for Research & Development and agreed the recommendation around the excellent work being carried out by the Research and Development team.
The Chairman thanked Professor MacLeod for attending the Committee following which she left the meeting.
The Committee agreed to report this item to the Board.
4.2 / Maternity – Update and Service Evaluation in Aberdeenshire
The Chairman welcomed Dr Humphrey, Consultant Midwife who presented to the Committee a Maternity update and service evaluation in Aberdeenshire.
Dr Humphrey provided some background information on the re-design of maternity services in Aberdeenshire in 2007.
Dr Humphrey highlighted to the Committee the 12 month evaluation on the changes in maternity services in Aberdeenshire. The evaluation found that the number of women choosing to give birth locally in birthing units had fallen and there was an increase in women giving birth in the Community Maternity Units.
Dr Humphrey brought to the Committee’s attention a number of challenges around sustaining a safe and consistent Birth Unit service in Aberdeenshire; low levels of intrapartum clinical activity, problems aroundsustaining the confidence and competence of midwives working within a Birth Unit model which may explain higher than average rates of intrapartum transfers observed in the study; Financial circumstance make it challenging to balance the disproportionate expense of providing on-call cover for birth units that were only accessed by a minority of women.
Dr Humphrey concluded and asked the Committee to approve and support this evaluation in the wider NHS Grampian Maternity Services Review Option appraisal.
Dr Cameron commented that if the service wasn’t safeconsideration should be given to closing these birthing units.
Dr Fitton referred to issues around women having their babies at home. Dr Humphrey mentioned that this evaluation did not include home births and that there was an on-going birth place study to monitor and review all birth transfers.
Mr Mackie asked the question around if two mothers were having their babies at the same time, when there was only one birthing unit, this was a high risk for transferring at the last minute. Dr Humphrey responded thatwomen triage by telephone, before accessingthe birthing unit, if occupied then go to Plan B. Dr Humphrey advised that there had not been any problems in relation to transfer.
Mrs Smith informed the Committee that maternity safety issues were addressed immediately and were incorporated in the Maternity Review.
The Committee agreed to support the option of this evaluation in the wider NHS Grampian Maternity Services Review.
The Committee thanked Dr Humphrey for presenting to the Committee and commented that the paper was excellent and very informative following which Dr Humphrey left the meeting.
4.3 / Medication Safety Committee Update (Strategic risk 853)
Ms Healy, Principal Pharmacist/Chair Medication Safety Committee was invited to the Committee to provide aMedication Safety Committee update.
Ms Healy referred to the update report and provided the background on the work of the Medication Safety Committee. The role and remit of this committee had been reviewed and membership updated to include GPs, CHPs, Dr Gray’s, professional development, academia and acute care.
Ms Healy informed theCommittee that a work plan had been developed and work was progressing identifying risks from medication incidents to ensure appropriate action had been taken to identify lessons to share learning.

Ms Healy mentioned that the profile for safety work had been raised by the SPSP initiative and the post of Medication Safety Officerhad made a big difference to what was being achieved.

Dr Dijkhuizen commended the work undertaken to convene an NHS Grampian Medication Safety Committee with membership across the organisation to address medication safety issues in NHS Grampian.
Dr Dijkhuizen highlighted 2 points for the Committee’s information:
1.Moray CHSCP had been successful in securing funding for a Patient Safety initiative around communication between primary and secondary care. Part of this work will be around medicine reconciliation and it may be useful for the Medication Safety Committee to link up with this work.
2.Dr Dijkhuizen attended the Medical Director’s meeting where there was a discussion on the development at a national levelof an e-health project for patient management system to electronically prescribe in Primary Care. The electronic prescribing was the single most patient safety issue which it was trying to formulate. Currently there was no schedule planned in Scotland for this project which could benefit both primary and secondary care.
Dr Fitton mentioned liaison Aberdeenshire CHP pharmacy links and commented that the group was not moving fast enough. Ms Healy gave more of an overview of NHS Grampian strategy rather than detail but was happy to answer any issues outside the meeting. The Committee suggested that the author of this report to be invited annually to report.
The Committee noted the report and agreed the recommendation to support the ongoing work of the Medication Safety Committee.
It was agreed by the Committee to report this item to the Board.
The Committee thanked Ms Healy for attending the Committee following which she left the meeting.
4.4 / Grampian-Wide Audit of Nursing Record Keeping (2010)
The Chairman welcomed Mrs B Lurie, Team Leader/Clinical Effectiveness Facilitator who was invited to the Committee to provide an update on the Grampian Wide Audit of Nursing Record Keeping.
Mrs Lurie provided the Committee with an update on the comparison of the audit results from 2009 and 2010 and an update on the implementation of the 2009 audit action plan.
Mrs Lurie highlighted key points from the report as detailed below:

Additional criteria was included to the 2010 audit, it was indicated by our internal auditors Price Waterhouse Cooper to includea question to ensure that storage of inpatients’ valuables and property was being recorded correctly in the nursing documentation. The recording of patients’ past medical history had not been reviewed. Both of these criteria were added to the data collection sheets in both audit packs.

Audit packs were emailed out to Sectors by the Clinical Effectiveness Facilitators. Preparatory work was undertaken before results were received which allowed Facilitators to contact nursing teams who had not returned their results.

  • The number of records audited in 2010 was 976. The excel spreadsheet automatically generated a score for each record audited and the maximum score that could be achieved was 100%. The overall scores for NHS Grampian in 2010, 93% of records achieved a score of 70% or above a considerable increase from 79% in 2009.
  • The overall audit results show that the score results showing good practice, some of them included; entries were legible and entries used the 24 hour clock.
  • Areas for improvement since 2009, these were in means of identifying the signature and designation of the person making the entries, allergy status recorded and the patient had been asked about allergies.
  • There was variation in the documentation used across NHS Grampian.
Mrs Lurie referred to the discussion section in the report and highlighted that although there had been an improvement from the audit in 2009, no individual criterion achieved 100%. However, patient forenames, surname, date of birth and address were all completed in 100% of the Patient Admission Documents(PAD) audited. The audit identified that there was a requirement to look at the PAD to address the parts that were not being completed by nursing staff eg signature and designation of person making entries and signature of person taking responsibility for patient’s valuables/special equipment/property, this can be addressed by reviewing the layout of the PAD and further training and education of staff.
Mrs Lurie informed the Committee that the medical record keeping audit was to be carried out in Dr Gray’s Hospital with future roll-out planned across hospitals in NHS Grampian. The Medical record keeping pilot at Dr Gray’s Hospital was on the 72 hour PAD documentation.
Allied Health Profession record audits would be completed by the end of February 2011.
On behalf of the Committee Mrs Smith commended the work undertaken by the Clinical Effectiveness Team around this audit.
Mrs Smith invited Mrs Lurie to attend theSenior Nursing Group to present the report and to highlight some of the areas for improvement. Mrs Smith agreed to feedback to the Committee the outcome from this meeting.
The Committee noted the report and agreed to support the ongoing programme to audit the standard of record keeping in NHS Grampian.
The Chairman thanked Mrs Lurie for attending the Committee, following which she left the meeting. / BL/ES
QUALITY & SAFETY
5.1 / Datix Occurrence Reporting (Strategic risk 853)
In the absence of Mrs Seaton, Technical Services Manager Mrs Tait referred to the Datix Occurrence Reporting and highlighted the key points as detailed below:
  • Mrs Seatonwas working hard to engagemedical staffregarding reporting of patient and safety incidents.
  • Monthly reportswere produced on all the high/catastrophic incidents and were reviewed by the Chief Operating Officer, Director of Nursing and Quality and Head of Clinical Governance & Risk Management to review the report for information on the level and completeness of the investigation and the recording of lessons learned and action taken.
  • Incident reporting culture,‘good’ reporting culture was perceived as,four no harm incidents for every one incident that caused harm, a target of 20% or less.
  • Overdue incidents managed within 7 days reducing to within 5 days.
  • To highlight,the report includes data on the top four most commonly reported patient related incidents; slips, trips, falls and collisions.
Mrs Tait referred to the recommendations in the report. The Committee commented that they found this report very worthwhile.
Dr Webster asked what extent was General Practice reporting on the Datix system and was there a source for patient safety incidents. Mrs Tait responded that funding had not been secured to rollout to General Practice. Ms Robbins mentioned that there were some salaried GPs recording on Datix and that there was a small amount of data. Currently there was no data on patient safety issues in general practice.