APPROVED
Minute of Meeting of the NHS Grampian Clinical Governance Committee
held on Friday 14th September 2012 at 1.30pm in the Conference Room, Summerfield House, Eday Road, Aberdeen
Present: / Mr C Muir, Non-Executive Board Member (Chairman)Councillor A McKay, Non-Executive Board Member
Mr T Mackie, Non-Executive Board Member
Mr M Scott, Non-Executive Board Member
In Attendance: / Mr Bruce Archibald, Service Planning Lead for Oral Health & Dentistry (Agenda item 3.2)
Mr Philip Bayman, (attended with Mrs Tait to observe)
Ms J Brown, Clinical Lead/Nurse Consultant(shadowing Mrs Smith)
Mr Richard Carey, Chief Executive
Mrs J Ferbrache, Programme Manager (Agenda Item 5.4)
Dr RGoldbeck,Clinical Governance Clinical Lead representative from Mental Health Services
Ms P Gowans, Clinical Governance Clinical Lead representative from Aberdeenshire
Mrs P Harrison, Infection Control Manager(attended for Agenda Item4.1)
Mr B Harrison, Clinical Director Specialisms Directorate(Agenda Item 6.2)
Dr J Hogg, Clinical Governance Lead, Moray CHP (video conferenced)
Councillor W Howatson, Chairman, NHS Grampian
Dr C Littlejohn, Specialty Registrar in Public Health(Agenda Item 8.8.1)
Mrs L Oldroyd, Nurse Consultant in Patient Safety & Experience (Agenda Item 6.1)
Ms M Parul, Clinical Effectiveness Facilitator (observing)
Mr D Pfleger, Director of Pharmacy and Medicines Management
Dr C Provan, Clinical Governance Lead, Aberdeen City CHP
Professor Sir L Ritchie, Director of Public Health
Mr D Shaw, Dental Practice Adviser
Mrs E Smith, Director of Nursing & Quality
Dr P Strachan, Chief Operating Officer (attended from 3.30pm onwards)
Mrs E Tait, Professional Lead for Clinical Governance
Dr D Webster, Consultant in Public Health Medicine (Agenda Item 8.8.1)
Dr S Wilkinson,Clinical Governance Clinical Lead representative from Acute Sector
Mrs F Shepherd, Committee Secretary
The Chairman welcomed everyone to the Committee and introduced those who were attending for agenda items and observing. Mr Muir also welcomed Councillor A McKay, Non-Executive Board Member and Professor Sir L Ritchie, Director of Public Health to their first Clinical Governance meeting.
The Chairmaninformed the Committee thata closed session would take place following the full meeting today at 4.30pm.
The Chairman informed the Committee that there would be two items to be included under AOCB; Use of Locum doctors in hospital settings and Results from 2012 Inpatient Experience Survey.
Item
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Apologies were received from Dr J Callender, Dr R Dijkhuizen, Dr J Fitton, Dr N Fluck, Professor N Haites, Professor V Maehle, Mr A Pilkington and Mrs N Urquhart.
MINUTE OF MEETING HELD ON 25th MAY 2012
The minute of the meeting held on 25th May 2012 was accepted as an accurate record subject to the amendment below:
Item 3.2 paragraph 11, to include “It was noted that a health needs assessment would inform the discussion”.
MATTERS ARISING
3.1 / Dental Incident Update Report
Sir Lewis referred to this agenda item and asked the Committee if it could be discussed at the Closed meeting due to its sensitive nature. The Committee agreed to this request.
The Chairman asked for all paper copies to be handed to Mrs Shepherd and for electronic copies to be deleted.
3.2 / Update on Decontamination of Dental Instruments in Primary Care – Timescales for Compliance
The Chairman welcomed Mr Archibald, Service Planning Lead for Oral Health and Dentistry to the Committee.
Mr Archibald presented to the Committee anupdatedreport on the NHS Grampian position on compliance in establishing an independent Local Decontamination Unit (LDU) in all clinical primary care dental premises.
Mr Archibald mentioned that the focus had been on inspections of at risk practices which might remain non-compliant by the end of December 2012. Three practices in NHS Grampian are currently not compliantbut arebeing supported and monitored:-2 practices had plans but not yet progressed to develop these and the other did not have appropriate plans in place as yet.
Mr Archibald informed the Committee that further guidance was expected from the Scottish Government at the end of September and depending on the content of this guidance, additional risks might be identified.
Mr Archibald referred to the recommendations and highlighted to the Committee that he would predict that one practice would not be compliant by the end of the year. Steps would be taken to provide support over the next few of months.
Mr Mackie referred to the non-compliant practices and asked if arrangements could be made to use an adjacent location or a Central Decontamination Unit (CDU). Mr Archibald explained this would be an acceptable and compliant solution but one practice had not engaged in a response to that effect.
Councillor Howatson referred to the NHS Grampian dental practice in a rural location leased to an independent dentist with very limited part-time service from these premises which was non-compliant. Mr Archibald informed the Committee this had progressed since writing the paper and this practice had made arrangements to use a central decontamination unit.
The Committee noted the actions and agreed the recommendations in the report.
The Committee agreed to report this item to the Board.
NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE PLAN FOR 2012 (Strategic risk 853)
4.1 / Healthcare Associated Infection Report
Mrs Harrison referred to the update report for Healthcare Associated Infection. This report summarised data for April, May & June 2012from the Infection Prevention and Control Team (IPCT) and staff throughout NHS Grampian. Mrs Harrison read through the report and highlighted each of the main points. Additional comments noted included:
- The Committee noted a slight increase in June of the Clostridium difficile infectionswhich may be related to the norovirus season.
- NHS Grampian achieved 99% compliance for hand hygiene.
- Cleaning and estates targets were being met in NHS Grampian.
- The Committee was informed that it was not possible for every Norovirus Prevalenceto be tested but from May – June, 4 wards had been affected and closed.
- From the graphs, the Healthcare Associate Infection Work Plan was produced for the year and mirrored the HAI Taskforce delivery plan.
- Healthcare Improvement Scotland had agreed to provide support to NHS Grampian in the implementation of the Decontamination of Patient Equipment Standard Operating Procedure across all hospital settings, including community hospitals.
Mrs Harrison provided the Committee with a verbal update on the recent Healthcare Environment Inspectorate (HEI) unannounced inspection at Aberdeen Royal Infirmary on the 7-8 August 2012. This was a follow-up inspection from July 2011. Mrs Harrison highlighted to the Committee that good compliance was observed by the inspection team and indicated that NHSGrampian was required to address further requirements and recommendations for improvements.
Dr Strachan advised the Committeethat this report was embargoed until the 18th September 2012 and the Committee was asked not to discuss out with this meeting. Dr Strachan took this opportunity to reiterate to the Committee the importance of highlighting all the good practice that had been demonstrated in NHS Grampian but stressed the importance of addressing the requirements and recommendations from this inspection.
The Committee noted the Healthcare Associated Infection report and noted the comments from the verbal report on the HEI Unannounced Inspection of Aberdeen Royal Infirmary.
QUALITY AND SAFETY (Strategic risk 853)
5.1 / Analysis of Strategic Risk No. 853 – Patient Safety is compromised and is not evidenced in practice
Mrs Smith provided the Committee with background information specifically thatrisk management arrangements for the review of individual strategic risks for theorganisationby the Executive Team.Each Sub-Committee of the Board had been asked to look at its pertinent risks. This was the first instance of the Clinical Governance Committee hadconsidered whether this paper provided sufficient assurance around the strategic risk 853.
The Committee heard that significant work had been undertaken across NHS Grampian to ensure patient safety continued to be of the highest priority. A wide range of plans were in place at all levels of the organisation. With all the arrangements in place, the Executive Team had considered changing the risk level to “medium”. After discussion it was agreed the risk should remain “high" as the organisation wanted to ensure staff continued to have patient safety at the top of their agenda.
DrHogg discussed the management changes at Dr Gray's Hospital and associated risks. Mr Carey tookthe opportunityto inform the Committeeof the management arrangements in Moray and Dr Gray’s hospital, Mr Adam Coldwells will be Acting General Manager for Moray CHSCP which allows Mr Andrew Fowlie to take up his temporary role in digital health.
The Chairmanacknowledgedthis was an important item to bring to this meeting and asked the Committee to look at the recommendations in the paper to be sufficiently assured around this strategic risk.
The Committee noted they were assured systems were in place to ensure patient safety continues to be of the highest priority and agreed the grading remains “high”.
The Committee agreed to report this item to the Board.
5.2 / Child Protection Update
Mrs Smith provided the Committee with an update on Child Protection in NHS Grampian. Mrs Smith highlighted to the Committee key items from the report prepared by Ms Smart, Consultant Nurse, Child Protection:
- Work was continuing to ensure delivery of appropriate training and learning opportunities for staff and workforce planning for the sustainability of services in the future.
- The issue around child protection training had been addressed with the recruitment of a Child Protection Trainer.
- There were currently 3 areas of e-health work in progress relating to child protection.
- The North East of Scotland Child Protection Committee (NESCPC) and Chief Officers agreed to move towards 3 separate child protection committees, linked to local authority areas. NESCPC would facilitate the transition to three separate committees by April 2013.
- NHS Grampian was involved in a number of elements of review associated with child protection; NHS Grampian chairs the North-East of Scotland Child Protection Committee Significant Case Portfolio Group, this group had responsibility for managing and commissioning reviews and ensuring reviews were undertaken to a suitable standard and degree of analysis.
- There were a number of national developments for child protection; HMIe inspection process; The North of Scotland Planning Group review and the new single police force in Scotland
Councillor Howatson asked why there were 3 separate child protectioncommittees. Mrs Smithreplied that this reflected the structure and accountabilities in local authorities and was supported by the local authorities.
The Committee noted the work undertaken and asked to receive a further report at a future meeting on the detail around the structure of the 3 separate child protection committees. / ES
5.3 / External Review Report including updates on recent visits
Mrs Tait referred to the External Review report and brought to the Committee’s attention NHS Grampian’s review activity over the past 3 months as below:
- Healthcare Improvement Scotland would be scrutinising and looking for improvement plans around Audit Scotlandreports.
- Awaiting report from the Quality Improvement Framework visit to review the process for Forensic Psychiatry which took place on the 22nd May 2012. This report would be received in October 2012 once all other Boards had been visited.
- There had been a Healthcare Environment Inspectorate (HEI) unannounced inspection at Aberdeen Royal Infirmary on the 7-8 August 2012. This report had been embargoed until the 18th September 2012. This was discussed under agenda item 4.1.
Mrs Tait brought to the Committee’s attention the key risks around the continuing volume of work involved in the roll-out and updating of the improvement plans. Mrs Tait mentioned that self-submissions take many hours to complete and require dedicated support from the clinical leads. OPAC and HEI continue to be one of the current priorities for managers across the Acute sector of NHS Grampian.
It is envisaged that Healthcare Improvement Scotland would move to include community hospitals within these reviews in the foreseeable future. The main risks associated with these were in relation to the financial impact of providing an appropriate environment for patients to be cared for and evidencing that those improvements were being made across all staff disciplines.
Mrs Tait referred to the document attached to the paper which was the work plan designed by Healthcare Improvement Scotland for 2012/13 and asked the Committees to note there were 85 threads of work from this organisation.
Sir Lewis referred to the suicide review work which was positive and brought to the Committees attention that there will be a new Mental Health Strategy which NHS Grampian will be expected to implement.
The Committee noted and agreed the recommendation in the report.
5.4 / Older People in Acute Care Collaborative
The Chairman welcomed Mrs Ferbrache, Programme Manager for the Elderly Collaborative to the meeting to provide the Committee with information on the NHS Grampian collaborative with NHS Tayside. Mrs Ferbrache mentioned this was an 18 month collaborative to improve the experience for Older People in Acute Care through the delivery ofa person-centred approach by November 2013.
Mrs Ferbrache referred to the report which included the challenges for NHS Grampian; data overload; ensuring the engagement for multidisciplinary teams and thecollation offall the quality work in relation to older people. Mrs Ferbrache commended the enthusiasm and participation of clinical teams in ARI and Dr Gray’s Hospital in this work.
In response to a question around measurement for this work to demonstrate improvement Mrs Ferbrache advised the importance of the change package and how to change: the next stage would be to measure improvements. It would be made clear to staff how to measure the improvements. Mrs Ferbrache agreed to present a further report in 6 months to demonstrate the measured improvements from this work.
Mrs Smith thanked Mrs Ferbrache for this useful report and mentioned a report would be presented at the next Committee meeting on the Older People and Dementia in Acute Care.
Mrs Ferbrache referred to the key risks and assured the Committee these risks were monitored and does not foresee any issues.
The Committeenoted the progress to date and asked to receive a further report in 6 months.
The Committee thanked Mrs Ferbrache for attending the Committee follow which she left the meeting.
The Committee agreed to report this item to the Board. / JF
5.5 / Significant Adverse Events
Mrs Smith referred to her paper and mentioned that she thought it beneficial to provide the Committee with the associated paperwork for this item; a copy of NHS Grampian’s Freedom of Information response and NHS Grampian’s response to Healthcare Improvement Scotland (HIS).
Mrs Smith provided background information to the Committee. Earlier this year Healthcare Improvement Scotland reviewed the arrangements in NHS Ayrshire & Arran for the management of significant adverse events at the request of the Cabinet Secretary, following a critical report from the Information Commissioner. NHS Grampian had completed a template, issued by HIS to all Health Boards,which described NHS Grampian’s arrangements for the management ofsignificant adverse events. In addition, a Freedom of Information (FOI) request had been sent by the BBC to all Health Boards asking for information about significant adverse events over the last 5 years.
Mrs Smith intimated that this report had been presented to the Committee for the purpose for sharinginformation which had been submitted on behalf of NHSGrampian and to agree a proposal for further work on this topic.
The Committee discussed this information submitted both to HIS and the FOI request. Mrs Smith highlighted that the key risk toNHSGrampianwas that the organisation failed to learn from serious adverse events but that this risk could be mitigated through a variety of means.
The Committee noted the recommendations, which included noting that the template had been submitted to HIS and the FOI request. Itwas agreedto hold a development session on this topic and to invite other Board members to the session on the 30th November 2012.
The Committee agreed to report this item to the Board.
PERSON CENTRED (Strategic risk 853)
6.1 / Ombudsman Reports – Process, Ownership and Recommendations
The Chairman welcomed Mrs Oldroyd, Nurse Consultant in Patient Safety & Experience to the meeting;she gave a brief explanation of her paper on the Ombudsman Reports process, ownership and recommendations to provide assurance that NHS Grampian’s systems and processes were robust and resulted in shared learning where appropriate.