APPROVED
Minute of Meeting of the NHS Grampian Clinical Governance Committee
held on Friday 24th February 2012 at 9.30am
in the Conference Room, Summerfield House, Eday Road, Aberdeen
Present: / Mr C Muir, Non-Executive Board Member (Chairman)Cllr LBell, Non-Executive Board Member
Mr T Mackie, Non-Executive Board Member
In Attendance: / Dr S Baguley, Clinical Director of eHealth (observing)
Dr J Callender, Clinical Governance Lead-Mental Health Services
Mr R Carey, Chief Executive
Ms S Carr, Associate Director of Allied Health Professionals, Adult Support & Protection Lead (Agenda Item 3.2)
Mr S Coady, Clinical Governance representative, Moray CHP
Dr R Dijkhuizen, Medical Director
Dr J Fitton, Clinical Governance Lead - Aberdeenshire
Ms J Fletcher, Interim General Manager, AberdeenCity
Mrs P Harrison, Infection Control Manager
Mr T O’Kelly, Acute Sector Clinical Governance Lead representative
Mr G Mortimer, General Manager Facilities and Estates (Agenda Item 3.1)
Dr C Provan, Clinical Governance Lead, Aberdeen City CHP
Professor D Reid, Research & Development Director (Agenda item 6.7.1)
Mr D Shaw, Dental Practice Adviser
Ms E Schrijver, Clinical Effectiveness Facilitator (observing)
Mrs E Smith, Director of Nursing & Quality
Ms G Thomson, Unit Operational Manager attended on behalf of Mr A Pilkington
Mrs E Tait, Professional Lead for Clinical Governance
Mrs N Urquhart, Public Representative
Mr A Wood, Risk Management Advisor (Agenda Item 3.1)
Mrs F Shepherd (Committee Secretary)
The Chairman welcomed everyone to the Committee and introduced those who were attending the Committee for the first time, for agenda items and observing.
The Chairmanbrought to the Committee’s attention the Quality and Safety in Healthcare event organised by NHS Grampian and the University of Aberdeen on the 21st May 2012. A flyer for this event was emailed to members to contact Fiona Shepherd to express an interest in attending. The Chairman informed the Committee that this event had been included on the Assurance Plan as one of the Development Sessions for the Committee.
Item
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Apologies were received from: Dr N Fluck, Dr J Hogg, Professor N Haites, Councillor W Howatson,Professor V Maehle, Mr A Pilkington and Mr M Scott.
MINUTE OF MEETING HELD ON 25thNOVEMBER 2011
The minute of the meeting held on 25th November 2011 was accepted as an accurate record.
NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE DEVELOPMENT(Strategic risk 853)
3.1 / Medical Equipment Multidisciplinary Group Update
The Chairman welcomed Mr Mortimer, General Manager Facilities and Estates, to the Committee to provide an update on Medical Equipment Multidisciplinary Group (MEMG).
Mr Mortimer highlighted to the Committee that this paper was to provide an update on current issues and direction of this group.
Mr Mortimer referred to his paper and mentioned that the group were focussing on the 4 recommendations from the 2004 Audit Scotland’s “Better Equipped to Care” report. These key issues were; risk centred performance reporting, balanced medium term capital planning, linking of training records and activities relating to medical equipment and had commonality between sub-structures of equipment registers and of training records. Mr Mortimer commented that these issues had been included on the action plan and were progressing.
Mr Mortimer also mentioned that the issue of the SGHD’s policy document CEL 35 (2010) enabled a change of the group in the role, remit and membership. To provide clarity around the key actions a paper was presented to the NHS Grampian Delivery Team and it was agreed that the new Chair (Mr Gary Mortimer) would review the role, remit, membership and direction of this group.
Mr Mortimer highlighted to the Committee that a key risk to the organisation was that no single committee/group retained responsibility for management/oversight of medical equipment within NHSG. Mr Mortimer proposed to the Committee that there should be one group across NHS Grampian.
Mrs Smith welcomed having a single point of contact for the organisation and asked if purchasing decisions were standardised as this had implications for training and patient safety. Mr Mortimer advised that this group wouldnot replace Joint Medical Equipment Committee (JMEC).
Mr Carey asked if any further support was required by the Executive Leads. Mr Mortimer responded that Executive Lead changeswouldbe raised with the Delivery Team.
Mr Bell asked where the inventory group sat and what the timescaleswere. Mr Mortimer answered that very soon the organisation wouldbe wireless enabled radio frequency tagged. We were using the technology and working on a plan.
Mr O’Kelly raised an issue around the supply of infusion pumps. As this was also a patient safety issue a decision should be made to ensure hospitals purchased and use the same pumps. Mr O’Kelly asked if this issue could be communicated to the Medical Equipment group for action. Mr Mortimer agreed to undertake this. / GM
The Committee noted the report and asked Mr Mortimer to include “start dates” and “complete dates” in the Medial Equipment Action Plan. The Committee requested to receive an update on this item in 6 months.
The Chairman thanked Mr Mortimer for providing the Committee with an update report, following which he left the meeting. / GM
3.2 / Adult Protection Update
The Chairman welcomed Ms Carr, Associate Director of Allied Health Professionals, Adult Support & Protection Lead, to the Committee. Ms Carr referred to thepaper to update the Clinical Governance Committee on progress.
The Committee were made aware of the low level of reporting incidents of abuse from NHS Grampian staff. Other concerns were highlighted, including access to medical investigations and GPs accessing appropriate training. An action plan was in place to address these issues. The Committee were pleased to hear that significant work had been undertaken by NHSGrampian and the local authority around a high profiled case involving the Mental Welfare Commission.
To provide the Committee with assurance Mr Carey asked Ms Carr to prepare a report for the next meeting on the recommendations from this enquiry and how they were being addressed by NHS Grampian.
Mr Mackie referred to learning from other service areas,for examplechild protection, by adapting documentation to local requirements. Ms Carr mentioned that a lot of work had been undertaken by referring to protocols used for child protection and adapting for adult protection legislation.
Dr Dijkhuizen asked if there were staff trained in providing advice to support staff on adult protection matters. Ms Carr mentioned that she had been contacted quite a lot to provide support to staff that were anxious about adult protection matters and the decision had been made totrain Adult Protection Champions across all sectors to provide support.
The Chairman suggested that the Sectors were asked to provide updates on adult protection for the next Clinical Governance Committee meeting.
Mr Bell commented that it would be beneficial for adult protection representatives to provide updates at Sector group meetings.
The Clinical Governance Committee noted and agreed the recommendations in the report.
The Committee decided that Adult Protectionwouldbe a regular item on the Clinical Governance Committee agenda for future meetings.
The Chairman thanked MsCarr for providing the Committee with an update report, following which she left the meeting.
The Committee agreed to report this item to the Board. / SC
Sectors
3.3 / Clinical Governance Committee Statement of Intent
The Chairman referred to the Statement of Intent and reminded the Committee of its aims and intentions. This had prompted a review of the document.
The Chairman informed the Committee that, at the Clinical Governance Committee agenda setting meeting,it had been agreed that a NHS Grampian Quality Strategy should be written. It was intended to incorporate the role of the Clinical Governance Committee in this document. The Chairman asked the Committee to note this paper and support the intention.
It was agreed to present the NHS Grampian Quality Strategy at the next meeting on the 25th May 2012. Dr Dijkhuizen made reference to the terminology in the Quality Strategy and suggested having a consistent approach in line with other NHS Grampian documents. Dr Dijkhuizen mentioned the emphasis on person centred which makes one think of the patient’s experience,a refreshing new angle on quality. Dr Dijkhuizen suggested usingthis as an opening sentence.
Mrs Tait informed the Committee that the Clinical Governance Committee Constitution would also be reviewed in line with the Committee elements in the Quality Strategy Document.
3.4 / Safety of Blood Samples Update
Dr Dijkhuizen provided the Committee with an update ona safe bar coding electronic system whichhad been identified and was being used in the high risk areas in NHS Grampian.
Dr Dijkhuizen asked the Committee if they felt that further information was required on this item to provide assurance to the Committee in the form of a development session. Mr Carey commented that a solution hadbeen identified and suggested a further report to provide the Committee with assurance that this had been resolved.
Dr Dijkhuizen agreed to ask Ms L Stout, Blood Transfusion Practitioner, to prepare apaper fora future Committee meeting.
Electronic Health Record(EHR)
Dr S Baguley, Clinical Director of eHealth took the opportunity to provide some background information on this programme. Mr Baguley mentioned that it was essential that the programme had clinical governance representation on the group and that there was a mechanism for the group to provide the Clinical Governance Committee with update reports.
The Chairman intimated the importance of receiving regular reports from eHealth membership group which should include a non - executive.
Mrs Tait mentioned that Mr Andrew Wood, Risk Management Advisor, already providedsome advice from the Unit to eHealth around the risk management issues. / RD
HEALTHCARE ASSOCIATED INFECTION REPORT & ANNUAL REPORT APRIL 2010 – MARCH 2011(Strategic risk 853)
Mrs Harrison referred to the update report and annual report for Healthcare Associated Infection. Mrs Harrison summarised the work of the Infection Prevention and Control Team (IPCT) and staff throughout NHS Grampian between April 2010 and March 2011 to reduce the risk to our patients from healthcare associated infection, the progress made and the significant challenges that had been faced.
During the year the surveillance of (SABs) in NHS Grampian had been greatly enhanced by the detailed discussion of each case by the IPCT, Microbiologists and Antimicrobial Pharmacists. This resulted in the number of cases of unknown origin reducing by almost half. There were no outbreaks of CDI anywhere in NHS Grampian between April 2010 and March 2011.
Data for breast surgery, hip and knee arthroplasty and Caesarean section surgical site infections demonstrated an overall downward trend.
NHS Grampian continued to participate fully in the National MRSA Screening Programme and implement the national screening protocol.
Work continued in 2010/11 to rationalise and further reduce (where possible) the use of antibiotics which were associated with a higher risk of causing Clostridium difficile infection.
Hand hygiene compliance throughout NHS Grampian remained well above the 90% compliance target.
Mr Carey mentioned that this was a very comprehensive report with a lot of work being undertaken by the team. Mr Carey referred to the downward trend in surgical site infections and asked how we comparedwith other Board areas.
Mrs Harrison mentioned that the quarterly report for Healthcare Improvement Scotland showed that Grampian was performing quite well. Mrs Harrison mentioned that18 months ago Grampian were outliers. Mrs Harrison offered to report on Surgical Site Inspections inthe next bi-monthly report.
CllrBell also commented on the amount of work undertaken by staff on Healthcare Associated Infection. CllrBell asked what would cause the slight increase above the 12 month average level for Clostridium difficile. It was intimated that this slight increase could be caused by winter infections. Dr Dijkhuizen also stated that there were more Clostridium difficile cases in the community rather than hospital based cases.
Dr Provan reminded the Committee that work continued with community pharmacies to reduce antibiotic prescribing. The graphs of 4Cs evidenced the effect of this work and the importance of continually reinforcing the message.
Mr O’Kelly asked if there were mechanisms to advertise good news stories to congratulate staff and inform the organisation. Mr Carey mentioned that we coulduse the usual mechanisms to share good news stories and that the Healthcare Associated Infection Annual Report was shared with the Partnership Forum. Mr Carey also mentioned that the Executive Leads were looking into establishing a scheme towards recognising good news stories within the organisation.
The Committee noted and commented that this was a well received and positive bi-monthly and Annual Report. The Committee also acknowledged the excellent work undertaken by staff and the Infection Control Team, which reflected well for NHS Grampian.
QUALITY & SAFETY(Strategic risk 853)
5.1 / External Reviews
5.1.1Update Report – Including updates on recent visits to NHS Grampian
Mrs Tait referred to the External Review report and brought to the Committee’s attention some of the current pieces of review work in Grampian, as below:
- A self - submission on ADHD was submitted on the 10th February 2012.
- A short video conferencing meeting with Healthcare Improvement Scotland and NHS Grampian to discuss information on current suicide reporting systems/processes in Grampian. This meeting was on the 22ndMarch 2012.
- Awaiting the report from the recent HEI inspection at Dr Gray’s Hospital.
- The draft report on the recent inspection of Older People in Acute Care inspectionat Aberdeen Royal Infirmary was due on 27th February 2012.
Mrs Tait also mentioned that she was working with the Head of Performance & Quality Improvement to create a system to performance manage external reviews to be visually available to Managers.
The Chairman suggested including External Reviews at a future Clinical Governance Committee development session to remind ourselves of the importanceof external reviews and to show what we were doing to comply with national standards.
The Committee noted and agreed the recommendation in the report to receive regular updates on this work.
5.2 / Child Protection Update
In the absence of Mr Pilkington, Mrs Smith provided the Committee with an update on Child Protection in NHS Grampian. Mrs Smith highlighted to the Committee key items in the report:
- The attached Action Plan was completed from the AberdeenCitysignificant case review recommendations.
- The Aberdeenshire significant case review summary of this case had been presented to NESCPC. Mrs Smith asked members to hand in their copies at the end of the meeting and delete any electronic copies.
Mrs Smith mentioned that child protection training for General Practitioners continued as an issue but workwas progressing to address this. Mrs Smith informed the Committee that the Protecting Children (Health)Group hadregular development sessions and most recently surveyedpartner agencies on “How well does NHS Grampian do in relation to child protection?” which identified many positive aspects and areas for improvement.
Dr Dijkhuizen referred to item 3.2; GP training continues to be an issue due to a lack of capacity to meet demand. Dr Dijkhuizen asked if it would be possible to investigate what other Boards were doing and at what level they were training their GPs. Dr Dijkhuizen commented that it might be that the trainingof GPs isan awareness session as if GPs were in any doubt they wouldalways ask for advice. Mrs Smith commented that work in this field was already being investigated. Mrs Smith agreed to provide an update at a future Committee meeting.
Mr Mackie referred to the incident case review and queried why it was the case that there was insufficient support provided to the child. He asked if there was too much bureaucracy and paperwork. Ms Fletcher intimated that there was an increasing volume of paperwork but this should never prevent support to vulnerable children. To safeguard against this there was regular case supervision for Health Visitors in AberdeenCity.
Mrs Tait mentioned that the recent child protection inspection in Moray looked at a paper trail throughout child protection case notes with a view to evidencing the work completed by all agencies.The Committee noted the report and acknowledgedthe work that was being progressed. / ES
5.3 / NHS Grampian Surgical Profile and Action Plan
As requested at the Committee meeting on the 26th August 2011 Mr O’Kelly presented an update on the progress against the Surgical Profile and Action Plan. The Surgical Profile Review Panel had met in June 2011 and the consensus was that NHS Grampian was making good use of the surgical profile to stimulate reflection in clinical practice. The panel did highlight the apparently low rate of total gastrectomy/oesophagectomy within Grampian as one area requiring further consideration. Further feedback was required on NHS Grampian’s plans to look into the increased length of stay following i) bariatric surgery at Aberdeen Royal Infirmary, and ii) transurethral prostatectomy for benign disease at Dr Gray’s Hospital.
The Clinical Governance Committee noted the report and was particularly pleased with the progress made to date and asked to receive update reports at future meetings.
The Committee noted the report and commented that it was encouraging to see so much work being undertaken in NHS Grampian and complimented staff involved.
The Committee agreed to report this item to the Board.
5.4 / NHS Grampian Food Fluid & Nutritional Care Group Update
The Chairman referred to the report prepared by the NHS Grampian Food, Fluid and Nutritional Care Group which provided the Committee with an update on the status following from the NHS Quality Improvement Scotland peer review in April 2009 which showed a marked improvement from the previous review. The Chairman highlighted the key risk; a challenge was to sustain good practice. The Chairman also mentioned that as noted in the report, following the change from NHS Quality Improvement Scotland to Healthcare Improvement Scotland, there had been no clarification of the status of standards for food fluid and nutrition.