APPROVED
Minute of Meeting of the NHS Grampian Clinical Governance Committee
held on Friday 25thFebruary 2011 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
In Attendance: / Dr J Callender, Clinical Governance Lead-Mental Health Services
Mr R Carey, Chief Executive
Ms K Dickson, Administrator (shadowing Mrs Shepherd)
Mrs M Duff, Clinical Governance Co-ordinator (observing)
Dr D Cameron, Chairman, NHS Grampian
Dr J Fitton, Clinical Governance Lead - Aberdeenshire
Dr J Hogg, Clinical Governance Lead, Moray representative (video conference)
Ms TJackson, Consultant Occupational Therapist in Stroke(Agenda Item 7.2)
Dr E Robertson, Clinical Governance Lead – Acute Sector
Ms C Ruxton, Deputy Director of HR (Agenda item 4.2)
Mr J Seaton, Technical Services Manager (Agenda Item 5.1)
Mr V Shields, Interim General Manager– Acute Sector(Agenda Item 8.7)
Mrs E Smith, Director ofNursing & Quality
Mr C Stewart, Clinical Governance Lead – Aberdeen City CHP
Mr J Stuart, Assistant Chief Executive, NHS Grampian(Agenda Item 4.1)
Mrs E Tait, Team Leader/Clinical Governance Co-ordinator
Mrs N Urquhart, Public Representative
Dr L Wilkie, Director of Public Health & Planning
Mrs F Shepherd (Committee Secretary)
The Chairman informed the Committee that due to unforeseen circumstances Ms J Warner, Director of Patient Safety and Performance Assessment for NHS QIS was not attending the meeting today, as scheduled.
The Chairman welcomed everyone to the Committee and introduced those who were attending the Committee for agenda items, to observe and shadow.
The Chairman intimated that at the Clinical Governance Committee agenda setting meeting it was proposed to allow additional time for the sector/service reportsat this meeting. It was also suggested to review the reporting of the Datix Occurrence report, Feedback, Claims and Child Protection. The Chairman suggested that these items be reported to the Committee twice yearly.
Item
/Action
- 1
Apologies were received from:
Mr L Bell, Dr S Cole, Dr R Dijkhuizen, Professor N Haites,Mrs P Harrison,Professor V Maehle Mr A Pilkington and Mr M Scott.
/ MINUTE OF MEETING HELD ON 12th NOVEMBER 2010
TheMinute of the meeting held on 12th November 2011was accepted by the membersthat attended the meeting, as an accurate record.
After the meeting the minute was ratified by the members of the Committeewhowere not in attendance.
- 1
Mrs Smith provided an update on child protection as mentioned at the previous meeting. The significant case review was progressing after the court case.
Mrs Tait informed the Committee that the Clinical Lead for Food, Fluid and Nutritional Care was not available to attend this meeting to provide an update on the outcomes of the work around the NHS Quality Scotland review.
3.1 / Grampian-Wide Audit of Nursing Record Keeping (2010) – update from discussions at the Senior Nursing Group
It was agreed at the previous meeting that Mrs Smith would feedback to the Committee, after discussing this item at the Senior Nursing Group to highlight areas for improvement. Mrs Smith informed the Committee that the Senior Nursing group were taking forward a number of issues:
- Looking at the areas that were not using the Patient Admission Documentation.
- Reviewing patient documentation.
- Developing anNHS Grampian Record Keeping Policy.
Mr Carey referred to the new Patient Admission Documentation. It was brought to his attention on a patient safety walkround that staff had concerns around the time taken to complete the patient admissiondocument. Mr Carey commented that after looking at the system, it does look impressive but stressed that it was important to listen to the views of those completing, to ensure that it was not too onerous.
Mrs Smith commented that there were interventions in place to get the balance right and to ensure practical to apply.
Mr Shields highlighted that when completing the documentation, time was being spent with the patient.
The Committee noted the verbal update on the work being undertaken by the Senior Nursing Group.
/ NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE DEVELOPMENT
4.1 / Efficiency and Productivity Programme Management Office (EPPMO) and Patient Safety
The Committee requested to receive a report from EPPMO to be assured that patient safety was given due consideration by the office when fulfilling its role for NHS Grampian.
The Chairman welcomed Mr Stuart, Assistant Chief Executive to the Committee to present the work being undertaken.
Mr Stuart referred to his paper and stated that this paper demonstrates the role of EPPMO giving examples of some projects which had a direct bearing whilst othershad no bearing on patient safety.
Mr Stuart highlighted that EPPMO provided support to operational managers to introducecost reduction measures within the sectors. The responsibility for achieving cost reductions rests with operational managers who were supported by the EPPMO to identify and achieve cost reductions. EPPMO also promotes best practice by ensuring that, where appropriate, initiatives developed at sector level were spread across the organisation.
To promote improvements in productivity and efficiencyin NHS Grampian,3 work streams had been implemented;Continuous Service Improvement (CSI), Safe Affordable Workforce (SAW) and EPPMO.
The three key functions of EPPMO were; identification and review of potential saving initiatives; co-ordination and monitoring of sector savings and making progress reports as required and the provision of professional support to departments on request/as directed.
Mr Stuart highlighted from the report some of thesaving initiatives as detailed below:
12 hour shift harmonisation: The risks were identified and action was taken by conducting an extensive literature review by the comparison of Datix figures. It concluded that there was no evidence to suggest any risk.
Shift rota planning: Wide range of shift rotas, fluctuation in staff numbers and skill mix. Action taken was the use of e-rostering software to improve efficiency and patient safety.
Mr Stuart highlighted to the Committee some of the examples of saving initiatives with no direct bearing on patient safety as; use of lease and pool cars; improving the efficiency and coverage of the TNT contract.
Mr Stuart informed the Committee that EPPMO does not directly implement change but provides the support and informs the decision making process.
Mr Mackie raised the following question regarding the 12 hour shift pattern.Were staff working no more that 12 hours including handovers? Mr Stuart responded that there was a 15 minute handover and there were numerous arrangements in place for handovers at the end of a shift.
The Committee asked how the efficiency savings were identified. Mr Stuart advised that they were received by email, mail contact, word of mouth, Face to Face meetings and the EPPMO intranet page.
The Chief Executive commented on the open culture of the organisation. All members of staff should be able to bring concerns to the attention of management to address or if more serious to investigate to resolve.
The Committee noted the report and recommendations to support the role and approach taken by the EPPMO towards patient safety.
4.2 / Update of Safe Affordable Workforce(SAW)
The Committee had asked for this item to be on the agenda to receive a report from the Director of Human Resources.
The Chairman welcomed Ms Ruxton, Deputy Director of Human Resources to the Committee. Ms Ruxton informed the Committee that the SAW process had now been in place within NHS Grampian for 12 months. This process had been agreed at the Grampian Area Partnership Forum in February 2010 and stated “it was essential we review the workforce to ensure it was safe, affordable and able to meet the challenges ahead”. The SAW work progressed using generic principles including ensuring continuing safe clinical care by staff and these were then cascaded through the organisation. A white-boarding exercise was used within each sector to evaluate their current workforce structures and design a new structure which was both safe and affordable. Once structures had been developed they were presented to challenge meetings, where there was opportunity to discuss risks around patient safety. Key risks had been indentified including the risk that final structures once implemented may not be fit for purpose. The continuing need to balance the financial situation against patient safety has been woven into the process to ensure that neither out ways the other.
The Committee noted the report and acknowledged the significant progress being made and note the risks associated with this project.
The Chairman thanked Ms Ruxton for presenting to the Committee following which Ms Ruxton left the Committee.
The Committee agreed that this item was to be reported to the Board.
4.3 / Medical Appraisal Update(Strategic risk 853)
In the absence of Dr Dijkhuizen. Dr Wilkie referred to the paper prepared by Mr Shemilt, Medical Workforce Manager.
Dr Wilkie provided the Committee with background information on the appraisal process for medical staff and highlighted systems and processes were in place for appraising medical staff.
Dr Wilkie also mentioned that the General Medical Council (GMC) would be commencing revalidation of medical staff in late 2012.
Dr Wilkie brought to the Committee’s attention the key risks associated with this process and highlighted that the risk formative process was a useful tool, and was no longer considered a risk; Initially there was a delay in putting systems and processes in place and work was ongoing to mirror nationally a process to embed in NHS Grampian.
Dr Hogg as the Primary Care Lead in Moray suggested using Protected Learning Time (PLT) for input from leads to local systems. As re-validation was a mandatory requirement it was suggested to contact RCGP to arrange a clinical forum to discuss if taking part in governance structures would allowcompletion of the re-validation criteria.
The Committee had a discussion around the implementation of the re-validation of medical staff in NHG Grampian and concerns were expressed whether clinicianswere able to get through the re-validation process and the risk to services if staff were not re-validated.
The Chief Executive commented that to ensure we were successful in the re-validation, to support medical staff, the organisation can provide training – geared to assurance.
Dr Wilkie asked if the Committee would like a paper prepared for a future meeting to provide a more detailed report on the re-validation.
Mr Mackie askedhow often medical staff were appraised. It was confirmed that medial appraisal was annually andto re-validation was 5 yearly.
Dr Roberson commented that it was in the interest of medical staff to be re-validated to continue to practice.
Dr Fitton informed the Committee that there was a robust system in Aberdeenshire since 2003 where anAppraisal Reference group arrange sessions for GP Appraisers.
Dr Cameron stated that anyone likely to fail re-validation the organisation should be informed.
The Committee noted the report and agreed that they would like to receive a report on the systems and processes in place around the re-validation of medical staff in NHS Grampian. / RD
4.4 / NHS Grampian Partnership with Independent Contractors (Strategic risk 586)
Mrs Smith presented the paper on behalf of Dr Dijkhuizen and highlighted that support from independent contractor’s falls under strategic risk 586.
Mrs Smith referred to the paper and detailedthe ongoing work with independent contractors to achieve strategic objectives as outlined in the NHS Grampian Health Plan. Mrs Smith highlighted that there were a number of examples of work detailed in the paper; working with General Practitioners to achieve the formation of cluster of General Practices by geographical areas; Appraisal of medical practitioners and arrangements with Ophthalmology, Dentistry and voluntary arrangement with the Estates Department for independent general dental practitioners relating to decontamination.
Mrs Smith highlighted to the Committee that as detailed in the paper this risk was low.
The Committee noted the activity around this work, accepted that the risk was low and asked for a further report in 12 months time.
The Committee agreed that this item was to be reported to the Board.
/ QUALITY & SAFETY
Mrs Smith reiterated that due to previous Clinical Governance Committee meetings running over it was proposed to allow more time for sector/service reports at the meeting. It was suggested and agreed to review the reporting of the Datix Occurrence report, Feedback, Claims and Child Protection on a 6 monthly basis.
5.1 / Datix Occurrence Reporting (Strategic risk 853)
Mrs J Seaton, Technical Services Manager was invited to attend the Clinical Governance Committee meeting to present on the Datix Occurrence Reporting system.
As discussed at the previous Committee meeting it was agreed that a fuller explanation on what happens to the ‘others’ category in the Datix system would be included in this report.
Mrs Seaton‘s report provided the Committee with details on incidents coded as ‘other’ and what was being done to manage these, as well as analysis of incidents that could be as a result of workforce changes; The monitoring of incidents that may be affected by workforce changes and included in this report the data on reporting levels, reporting culture, incident management and the top four most commonly reported patient related incidents.
Mrs Seaton regularly reviews and recodes incidents coded as ‘other’. Following the recoding exercise the coding guide was reviewed and updated to reflect any changes.
Mrs Seaton talked to the report and highlighted the key points from the report as detailed below:
- The incident data relating to patient care and safety, the analysed data was coded as; a lack of trained/skilled staff; inadequate handovers/failure to answer bleep and failure to monitor, including lack of clinical assistance.
- With the inclusion on the Datix icon on the intranet there had been an Increase in reporting on the Datix system.
- Page 7 Obstetrics teams are high users of the system.The Obstetrics service are now using Datix to record all clinical complications and other incidents, a lot of work was being undertaken by the Datix team to support the service.
Dr Hogg mentioned to the Committee that it can be a challenge engaging clinical staff to report on the Datix system. Clinicians had been trained on the system and to ensure there was a link with primary care and secondary care Dr Hogg proposed linking through the Primary Care Safety Programme. Dr Hogg mentioned that a programme was in place with medical staff in Elgin to encourage using the Datix system.
Mr Shields mentioned that he was aware of this issue which had been highlighted by user groups. Mr Shields informed the Committee that a plan was in place to promote engagement of medical staff on this issue.
The Committee were reminded that all incidentswere reviewed by managers.
Mrs Seaton informed the Committee that she was attending the GP Sub Committee to plan the roll-out of Datix to GP’sand to identify resources to provide support and training on the system. Mrs Seaton provided information on the costs as 50 hours training was requiredand 45 hours administration to get GP’s on the Datix system.
The Committee noted the report and agreed to amend the duration for the Committee to receive Datix reports twice yearly. It was noted that at a future meeting would be in the form of a joint report including Datix incidents, claims and feedback.
/ HEALTHCARE ASSOCIATED INFECTION UPDATE
In the absence of Mrs Harrison and Dr Dijkhuizen. Mr Carey referred to the update report on Healthcare Associated Infection and highlighted that this report was also presented to the NHS Grampian Board. Mr Carey commented that there were no main concerns in this report and good progress was being made with a significant decrease in the number of infections across Grampian and that the production and publicising of the antibiotic guidelines had been beneficial in reducing CDI rates.
Dr Cameron informed the Committee that the Scottish Government were happy with the progress NHS Grampian was making.
The Committee noted the updated report and asked to continue to be kept fully informed of the ongoing improvement work.
/ EXTERNAL REVIEWS UPDATE
7.1 / Update Report
Mrs Tait referred to the report and explained that the revised layout of reporting was an extract of the Unit’s external review database. This would provide regular updates to the Committee on all external reviews that had taken place and reviews that were planned for in NHS Grampian.