Minute of Nhs Fife Clinical Governance Committee
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MINUTE OF NHS FIFE CLINICAL GOVERNANCE COMMITTEE
HELD ON WEDNESDAY 9 DECEMBER 2015 AT 2.30PM IN THE
BOARD ROOM HAYFIELD CLINIC, VICTORA HOSPITAL, KIRKCALDY
Present:
Dr L Bisset, Chair
Mrs W Brown, Employee Director
Mr S Little, Non Executive Board Member
In Attendance:
Dr R Cargill, Associate Medical Director, Acute Services Division
Dr F Elliot, Medical Director NHS Fife
Mrs G Fenton, Associate Director of Nursing/Head of Service Delivery, GNEF Community Health Service
Mr P Hawkins, Chief Executive
Dr A McGovern, Clinical Director, D&WF Community Health Service
Professor S McLean, Director of Acute Services
Mrs E Muir, Clinical Effectiveness Co-ordinator, NHS Fife
Ms H Paterson, Director of Nursing NHS Fife
Dr D Reid, Clinical Director, K&L Community Health Service
Ms Andrea Smith, Lead Pharmacist – Pharmacy Services
Dr J Wilson, Acting Chair, ASD CGC
Mrs H Woodburn, Quality & Clinical Governance Lead
Ms C Dziech, PA to Medical Director NHS Fife (note taker)
MINUTEREF /
ACTION
024/15 /CHAIRPERSON’S WELCOME AND OPENING REMARKS
Dr Bisset welcomed Mr Hawkins to his first meeting of the NHSFCGC. Going forward Mr Hawkins will be in regular attendance at the meetings.Dr Bisset also welcomed Ms Andrea Smith who was attending for Mrs E McPhail.
025/15 /
DECLARATION OF MEMBERS’ INTERESTS
There were no declarations of interest from those present.026/15 /
APOLOGIES FOR ABSENCE
Apologies for absence were noted from Dr G Birnie, Dr M Hannah and Mrs E McPhail.In noting Dr Birnie’s apologies Dr Bisset asked that thanks be formally recorded for Dr Birnie’s contribution over the years to not only toClinical Governance but to medicine and the patients of Fife.
027/15 /
MINUTES OF PREVIOUS MEETING HELD ON WEDNESDAY 14 OCTOBER 2015
The notes of the meeting held on 14 October 2015 were approved.028/15 /
MATTERS ARISING
a)Action List029/15 /
GOVERNANCE ITEMS
029/15 /a)Health Check
The Committee noted the NHS Fife Healthcheck report for July – August 2015. The Committee were advised Mrs Paterson and Dr Elliot take an overall view of the Healthcheck before it is presented to the Board. Dr Bisset suggested it would be helpful to develop a quality report for consideration at NHSFCGC then taken to the Board. Members were asked to feedback views to Mrs Paterson and Dr Elliot. Mr Hawkins also highlighted it was important the information within the performance report had been considered by NHSFCGC before going to the Board.
/ ALL029/15 /
b)Chief Executive Report
Mr Hawkins advised overall performance was good. AU1 was working well. DD was currently sitting at 100 but it is hoped this will be down to 80 by next week.
The closure of the Forth Road Bridge was causing issues for staff and patients but a Hospital Control Room had been set up and were reporting no clinical risks at this stage. Dr Elliot advised that any issues arising with the Community i.e. home visits, staff / GPs in West were being discussed and dealt with accordingly.
The Clinical Strategy Steering Group had now been set up and would meet in the New Year. The Governance Review would be presentedto the next Board in draft.
IJB work underway and is will be important that it is clinically led.
Projects were underway within the PMO and will be discussed at F&R and the Board.
029/15 /c)Midwifery LSA Annual Report
c/f from October 2015This item to be carried forward to February 2016. /
YB
029/15 / d)Palliative & End Of Life Report (Living & Dying Well)This item to be carried forward to February 2016
029/15 / e) Patient Feedback / Complaints Q2 Jul – Sep 2015
The Committee considered and noted the NHS Fife Clinical Governance Patient Feedback Report for the period July – September 2015.
Mr Little advised the figures in the report were helpful but asked if they could provide more information in future. An example being do we go back to complainants once the complaint has been resolved? Mr Paterson advised if complainants come back cases will be re-opened but in some instances the concerns may not go to formal complaint.
Mrs Paterson advised the Scottish Health Council is currently working to look at the complaints handling processes as a whole and are at Phase 2 of their work.
Dr Wilson asked from a patient centred complaint would we consider asking what we could do to make experience better (one question). Mrs Paterson advised work is underway in Queen Margaret to collect feedback. Mr Hawkins advised there was nothing to stop ASD taking this issue forward at clinician level.
Mr Hawkins advised there is an issue with the quality of response letters to complainants and stressed it was important to answer all the questions and concerns. It was suggested that Action Plans need to be prepared from complaints to take forward issues to conclusion.
029/15 / f) Tissue & Organ Donation Report
This item to be carried forward to February 2016.
029/15 / g) Management of Adverse Events Improvement Plan Update
This item to be carried forward to February 2016.
029/15 / h) GP Staff & Clinical Governance Report 2014
This item to be carried forward to February 2016.
029/15 / I)Controlled Drugs Local Intelligence Network – Terms of Reference
The Committee noted the updated Terms of Reference. Dr Elliot advised, as Accountable Officer, it was a statutory requirement for the Controlled Drugs Local Intelligence Network (LIN) to report to NHSCGC.
Mr Hawkins asked how issues come to NHSFCGC. Dr Elliot advised LIN was an information forum. Dr Bisset confirmed reports are taken to the Area Drugs and Therapy Committee for consideration before being brought to NHSFCGC.
029/15 / j)Organisational Development & Learning Annual Report 2014 – 2015 (to include Medical Education & Practice Development
This item to be carried forward to February 2016.
029/15 /
k)Horizon Tracker Update
The Committee noted the NHS Fife Guidance Horizon Tracker and status of the items on the Tracker.029/15 /
l)HMSR Report
Dr Elliot advised this report sets out the chronology of the HSMR reports that were submitted to the NHS Fife Operational Division and successor Acute Services Division Clinical Governance Committees since reporting of HSMR commenced in 2009.The chronology demonstrates that there is evidence in the regular reports from the AMD of the ASD to the ASD Clinical Governance Committee that there is a robust process in place for the monitoring and reporting of both HSMR and crude mortality in NHS Fife. These minutes are then considered at each meeting of the NHSFCGC.
Dr Bisset confirmed this was a thorough report which highlighted mechanisms were in place to report crude mortality. It was also worth noting that HSMR rates have gone down and NHS Fife is the second best Board in Scotland. Mr Little added we should celebrate the 20% reduction and make this known to the public of Fife.
Professor McLean added that the ASD have a weekly and monthly HSMR and crude mortality discussion and if HSMR has increased there is an opportunity to explore why and resolve any issues contributing to mortality.
Mr Little asked about the dynamics in changes of care provided and asked if the changes in settings should be looked at. Dr Elliot advised this was a complex issue and it would be difficult to draw comparisons. Dr Simpson’s report on cardiac arrests and early recognition of deteriorating patients would be brought back to NHSFCGC and Dr Bisset asked if this would need to be reported to the Board in a Private Session rather than an open public Board meeting. / FME/LB
029/15 /
m)Medical Revalidation Report 2014-2015
Dr Elliot advised the report from HealthcareImprovement Scotland gives an overview of medical revalidation in Scotland.The NHS Fife seventh Annual Report included with the papers also confirms that NHS Fife has a well organised appraisal team and system in place to ensure all doctors can fulfil the GMC requirements for revalidation.
Dr Elliot highlighted that action points for consideration during 2015 – 2016 are:
Develop the system which provides all doctors within secondary care up to date and relevant clinical activity information.
Ensure there are enough NES trained appraisers to undertake appraisals of all doctors
Finalise and implement the current draft policy for remediation, rehabilitation and targeted support.
Dr Elliot highlighted that we are currently struggling for secondary care appraisers and thought has to be given to highlight and encourage staff within the organisation to consider the role of appraiser. Dr Cargill said he felt this was a professional standards issue. Although the appraiser role is time consuming Consultants have a duty within their professional standing to consider and take on the role of appraiser. Dr Elliot also highlighted she had met with GP appraisers who have a very thorough system for appraisal which is not the same as secondary care and suggested perhaps some of the processes within their system could be built in to the consultant process.
Mrs Paterson advised that Nurse Revalidation would be an item for discussion at the NHSFCGC meeting in February 2016. /
HP
Mr Hawkins advised that there may be a proportion of nursing staff will not wish to be revalidated. Mrs Paterson advised approximately 6% of staff may not revalidate. Dr Elliot advised when consultant revalidation was introduced there was a spike in retirals and this may be the case for nursing. Mr Hawkins said consideration should be given to looking at the statistics to ensure risks can be identified and mitigated. / HP029/15 /
n)Yellow Card Reporting in Fife 2014/2015
Dr Elliot advised the attached reports; 2014 -2015 Annual Report for Yellow Card Centre Scotland along with the report for NHS Fife were for the NHSFCGC to note.Mr Little queried why there were no psychiatric drugs included within the report. Dr Elliot agreed to look in to this and report back to the Committee /
FME
Dr Bisset referred to Page 8 of the main report Table 3 – Serious reports over the last five years and asked if it would be helpful to have a breakdown of the figures for a more in-depth review or would the amount of work required by justified for what we need. Dr Elliot agreed to discuss with ADTC and MH colleagues and feedback to the Committee. / FME029/15 /
o) HEI Inspection to QMH 29&30 Sept 2015
Mrs Paterson advised this report sets out the findings from the Healthcare Environment Inspectorate unannounced inspection to Queen Margaret Hospital from Tuesday 29 to Wednesday 30 September 2015.The Inspection focussed on:
Standard 2 – Education to support the prevention and control of infection
Standard 3 – Communications between organisations and with the patient or their representative
Standard 6 – Infection prevention and control policies; procedures and guidance; and
Standard 7 – Insertion and maintenance of invasive devices
Standard 8 - Decontamination
The following areas were inspected; Ward 4 (Mental Health), Ward 5 (Geriatric/Medical), Ward 6 (Geriatric rehabilitation) and Ward 7 (long term / end of life care).
11 patient interviews were carried out and 26 patient questionnaires completed.
It was noted the hospital did well in;:
-Peripheral venous catheters were well managed
-Staff adhered to the majority of standard infection prevention and control precautions.
It was highlighted the hospital could do better:
Standard infection control precautions audits must be completed in line with local policy.
The inspection resulted in four requirements. The requirements are linked to compliance with the Healthcare Improvement Scotland HAI standards. A full list of the requirements can be found in Appendix 1 of the report.
Mrs Paterson advised the Inspection Teams seem to be taking a different stance during Inspection Visits and were very supportive of staff and gave immediate feedback which went down well with the staff.
Mr Little advised he was disappointed to see contaminated mattresses highlighted in the report and asked if this particular Department set their own standards. Mrs Paterson advised there were consistent practices in place across all in-patient areas.
Dr Bisset said he was encouraged to see this was a much more positive report. It was also encouraging to see HEI were more responsive. Mr Hawkins said there were also negatives within the report and asked how the Committee can be assured these will be taken forward. Dr Bisset advised these issues will come back to the Committee. Mrs Paterson also highlighted Infection Control will bring back an update via Peer Review.
029/15 /p) Internal Audit Paper
Dr Elliot asked the Committee to note the Clinical Governance Strategy and Assurance Report No B15/15.The Committee noted the audit opinion is Category C – Adequate – Business objectives are likely to be achieved. However, improvements are required to enhance the adequacy / effectiveness of risk management, control and governance. Audit has highlighted that the impending revision of the Clinical Governance Strategy, already in progress, will address at least some of the issues identified through this report and other audit feedback.
The Committee noted the Action Plan will be reported to QSGG.
029/15 /q) Clinical Governance Reporting Template
Mrs Woodburn advised it is proposed this new template - Progress Update to NHS Fife Clinical Governance Committee with a summary of the meeting will be used for every report submitted to the NHSFCGC.Dr Bisset advised this template will help focus on information required and would be implemented at the next NHSFCGC meeting in February 2016.
The Committee was asked to feedback any comments directly to Mrs Woodburn. /
ALL
Mrs Woodburn advised the second template (Quality Reporting) will link to Healthcheck. Committee members are to consider and feedback comments to Mrs Woodburn.
/ALL
029/15 /r) Healthcare Improvement Scotland Annual Report
2014 – 2015 - FOR INFORMATION ONLY
This report is submitted to the Committee for information.030/15 /
CLINICAL STRATEGY
Clinical Strategy Development
Dr Elliot advised Clinical Strategy Development had been added as a standing item to the NHSFCGC agenda to provide an update at each meeting on progress.Dr Elliot highlighted the Clinical Strategy Workstream Members were now established and work can now move forward. Mr Hawkins highlighted there will be enormous changes for the organisation and challenges for clinical governance. Mr Hawkins also advised clinicians need to drive this and influence change.
Mr Little highlighted there were no public members on the Steering Group and said he felt the public needs to be included. Mrs Paterson advised it is planned to take this forward through public engagement.
Mr Hawkins advised Mr Little there may be concerns around disinvestment if we identify that some services may no longer be provided in Fife and we need to ensure appropriate plans are in place before sharing information with the public. Dr Bisset advised he was comfortable with the public engagement plan as set out in Appendix 5 of the report.
Dr Bisset said he was reassured with the plans in place for input to the workstreams and advised any potential clinical changes would also need to be discussed with the Workstream.
031/15 /ITEMS FOR DISCUSSION
031/15 /a)NHSFCGC Work Plan
The Committee noted the Work Plan for 2015/16.031/15 /
b)NHSFCGC Map
The Committee noted the review of outstanding items on the Clinical Governance map for 2015-2016. Dr Bisset proposed the map be brought to a NHSFCGC meeting. Mrs Muir advised the map is included in the End of Year Assurance statement.032/15 / EXECUTIVE LEADS’ CLINICAL GOVERNANCE REPORTS
Dr Bisset advised all items under this item would be taken without comment unless any particular issues were raised.
032/15 / a)ASD CGC
Unconfirmed note – 7 October 2015
Nil to report.
032/15 / b)NHS Fife Community Services - Dunfermline & West Fife Clinical Governance Group – 17 November 2015
Not available - Meeting not quorate so cancelled
Dr McGovern highlighted due to the change in staffing arrangements within Community Services it was proving difficult to make the meetings quorate. Dr McGovern assured Dr Bisset and the Committee that clinical governance arrangements are part of the service within Community Services. Mr Hawkins agreed to speak to Sandy Riddell about these difficulties. / PH
032/15 / c)NHS Fife Community Services - Glenrothes & North East Fife – 6 October 2015
Nil to report.
032/15 / d)NHS Fife Community Services - Kirkcaldy & Levenmouth – 12 November 2015
Nil to report. Dr Reid advised business is carrying on as normal within the new structure.
032/15 /
e)Quality Safety & Governance Group – Unconfirmed note of meeting held on 28 October 2015
Not available – meeting cancelledNil to report.
032/15 /
f)Public Health Governance Group – 12 November 2015
Not available – meeting cancelledNil to report.
033/15 /
MINUTES FROM LINKED COMMITTEES – FOR INFORMATION ONLY
033/15 / a) Infection Control Committee7 October 2015
The above minutes were noted by the Committee.
033/15 / b)Area Radiation Protection
October 2015
The above minutes were noted by the Committee.
033/15 / c)Ehealth Board
19 November 2015
The above minutes were noted by the Committee.
033/15 / d) Fife Area Drugs & Therapeutics Committee – Unconfirmed minutes - 21 October 2015
The above minutes were noted by the Committee.
034/15 / AOCB
a)IMER Policy
Dr Elliot advised she had recently updated the current IMER Policy and would share this with the Area Radiation Protection Committee and asked them to review and accept the changes she has made.
b)Attendance at Workshops
Mr Hawkins asked members to consider any future Workshops they may wish to be invited to and to let Dr Elliot’s office know.
035/15 /
DATE OF NEXT MEETING
Dr Elliot advised that the future dates proposed for the NHSFCGC clashed with Mr Hawkins attendance at the Board Chief Executive meetings in 2016. New dates would be looked at and issued in due course. / CDDr Elliot also advised in terms of the Clinical Strategy it had been agreed extra meetings of the NHSFCGC should be held over the first six months of 2016 and these dates will be issued in due course.
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