CLINICAL QUALITY GOVERNANCE COMMITTEE MINUTES

Transcription

1 Date: Friday, 23 rd August 2013 Time: pm Venue: Seminar Room 1 CLINICAL QUALITY GOVERNANCE COMMITTEE Present: Anthony Goldstone Guy Billington Geraldine Edge Benjamin Jacobs Matt Shaw Camilla Wiley Unit Representative: Patrick Harding Kim Harris Iva Hauptmannova Lynn Hill Jackie Humphreys Helen Landers-Flynn Beccy Maslin Jane Shentall Adam Thwaites Roxy Zarnegar Apologies: Tara Argent Kathryn Corder Rob Hurd Jonathan Miles Patsy Spence In attendance: Siba Agbeyegbe Pat Jones MINUTES RNOH Chairman (AHG) - Chair Non-Executive Director Clinical Director for Clinical Governance Consultant Paediatrician Medical Director Director of Nursing AHP Service Improvement Lead Customer Complaints and PALs Co-ordinator Research and Development Manager Chief Operating Officer/Deputy CEO Matron / Theatres Matron/Adult Wards Project and Productive Ward Nurse Head of Operations, Direct Care Services Transformation Programme Manager Consultant Anaesthetist Head of Operations, Clinical Support Services Deputy Director of Nursing Chief Executive Consultant Orthopaedic Surgeon Deputy Director of Operations and Transformation Trust Secretary Patient Group representative Attachment M Item Title 1. APOLOGIES FOR ABSENCE Apologies were noted. The Chair welcomed the new Trust Secretary Siba Agbeyegbe who was observing this committee meeting. He then remarked that in light of PFI and FT, Monitor would be particularly reviewing this committee and all the issues relating to the patient experience. It was important reports and presentations be accurate and well-argued and that relevant actions are taken. 2. MINUTES FOR THE MEETING HELD ON FRIDAY 26 th July 2013 The minutes of the previous Clinical Quality Governance Committee were agreed as a true record save for the following points: 7.2 correct the spelling to anonymised. Only the patient name need be anonymised within RCAs-relevant staff can be noted by name and job title.

2 3. MATTERS ARISING Delayed Discharges - The committee was advised if a patient stays longer than expected we may not be paid the full daily rate although other factors would be taken into account. There is a trim point whereby a procedure has a set stay length and if this is exceeded we are not paid for the additional days stayed. Stem cell patients update LH advised that RMS have recently passed the MHRA inspection and will be re-opening on 16 th September Overbooked and overrun clinic incidents AT to circulate the data by clinician. MS confirmed he is meeting Jonathan Miles to review a realignment of clinic times and report back at the next committee Action: Adam Thwaites to circulate data, by clinician Action: Mat Shaw and Jonathan Miles meeting to review job plans and clinic times. Mat Shaw to report back to the next committee Review of Clinical Policies IM&T have advised that the automated Review Notification system will be working by the end of October as there were still a few issues around standardising policy formats with version numbers. The committee asked that they try to implement by the end of September. Action: Camilla Wiley to request IM&T implement the Review Notification system by the end of September 2013 RZ added while we advise junior doctors to adhere to our policies it is often difficult to navigate the Grapevine system to locate relevant policies, and despite incident reporting these complaints have not been actioned. Action: IT Lead to be identified and questioned about policies on Grapevine. CW to contact Saroj Patel Litigation Report MS confirmed that he had met with our lawyers, Capsticks, along with several other colleagues, to discuss consenting particularly for our high risk cases, including cancer patients. Over the next two months he will put together an action plan and review how the recommendations can be implemented. Initial recommendations were for Consultant involvement at pre-assessment along with individual specialties information leaflets. Action: Mat Shaw to feedback an Action Plan for October committee Root Cause Analysis leads for investigations AT listed the service managers who are now leading on the current RCAs being undertaken. It was noted that several people have undertaken the RCA training course but no medical staff have attended. The committee felt that although they are involved in the process the next step would be to lead the investigations. Recommendation: Medical staff to lead RCA investigations where relevant Safeguarding adults Action Plan CW advised Luisa Orlandi would first present and discuss her Action Plan at the next Safeguarding Adults Group and then it could be brought to this committee Action: Camilla Wiley to contact Luisa Orlandi to set a date for bringing the Action Plan to this committee Radiation report comparing incident reporting with other similar trusts Action: Lynn Hill to contact the Care Quality Commission to request information to compare incident reporting with other similar trusts

3 Inpatient bed re-alignment MS updated the committee saying there is a working group looking at all issues from infection control PODs to nursing numbers and training on the wards. The aim is to implement the realignment by December AT will present the logistical details at the next committee Action: Adam Thwaites to present the logistical details at the next committee RCA57 Death in Theatres JH confirmed that centralised bookings now inform theatres of high risk cases in order that early reviews and skill mix can be discussed. RCA59 Diathermy burn during surgery MS confirmed he was contacting the registrars involved although one now works in Toronto. JH advised that 3 new diathermy machines are in service and appropriate training for staff has been undertaken and recorded. RCA53 Growth rod delay and RCA53 Theatre delays due to lack of kit JH updated the committee on the action plans which related to both RCAs. Some actions have been completed while there is some work in progress. JH outlined the processes that are now in place from scheduling, earlier reviews of equipment and skill mix required. All but one consultant carries out the team brief on the day. An audit is to be carried out shortly and any non-compliance with morning team briefs will be notified to this committee. Action: Jackie Humphreys to notify the committee of any noncompliance with the team brief once the audit has been completed Theatres LH reported on the disarray of theatre supplies, having visited Theatre 3 the previous night. The committee went on to discuss the issues further. MS explained the purpose of e-stock was to reduce the stock levels, ensure ease of locating stock and to review stock values. The committee asked if the manufacturers should be responsible for checking out-of-date stock on the shelves although theatre staff are checking the prosthesis dates on trolleys; responsibility for checking dates was not clear. MS felt the e- stock initiative was now linked with e-fin and although e-stock allows for monitoring of prosthetic usage and costings, the processes and storage needs to be reviewed. The committee asked that Procurement be invited to the next committee in order to explain. Additionally this should be an agenda item to update at the next Board meeting. Action: Camilla Wiley to invite Procurement to answer questions around theatre stores to the next committee meeting as well as the Trust Board 4. PATIENT EXPERIENCE REPORT The committee had reviewed the results and noted CW s comments. The Serious Incident (SI) related to a diarrhoea and vomiting outbreak. Fortunately not Norovirus and each case had proved unrelated. Drug errors were reduced although there was a re-occurrence of controlled drugs (CDs) missing in the private patients unit (PPU). Individual tablets had been popped out of the blister packs. CW confirmed the police have been informed and the case is being investigated. VTE assessment compliance has fallen; it is important we stay at 95% and above as this is a CQUIN. It was confirmed that theatre staff are fully aware not to start an operation without the VTE assessment completed. RZ advised that the ward clerks enter the data on ics at the time of discharge and they have been reminded of the importance of capturing this information.

4 Regarding the long outstanding complaint MS said he had written to the consultant that it was not acceptable and they have since reported their comments. The high risk nursing complaint was explained by HL-F. The nurse involved has been spoken to and shown the letter of complaint. She has now been asked to give her response in writing once she returns from annual leave next week. As there are possibly other factors involved the committee agreed this would be discussed at the Board once the full investigation had taken place. Nevertheless it was felt that the non-executives should be informed in case the story was leaked beforehand. The committee acknowledged that as this may possibly lead to a staff disciplinary due process should be followed and appropriate support given to the staff member. CW said she had met the Lead Nurse for Jackson Burrows regarding the negative Friends & Family comments, explaining that this is a high throughput ward with up to 2 or 3 patients admitted to a bed per day. There were no identifiable trends in terms of staff on duty and the ward was not understaffed. LH added that during her night visit she had spoken with staff and patients and all the comments were positive about the care on the ward. Pharmacy are looking at our policy to allow short stay patients to continue self-medicating while they are inpatients. CW agreed the interpretation of the Friends and Family data was difficult to calculate but on a positive note confirmed that Margaret Harte Ward was in the top 10 nationally. 5. DIVISIONAL REPORT RZ gave a presentation linking in with data on Insight on behalf of the Chronic Pain division. Activity related to outpatients, inpatients and pain management rehabilitation programme was presented. RZ advised that a new consultant had recently started and the service was again able to take new GP referrals. It was noted that the high number of re-admissions related to patients discharging on Fridays and being re-admitted on Mondays for the PMP; these are planned readmissions. RZ advised we are a referral centre for pain management rehabilitation in highly disabled patients as we are we are one of only 2 centres in the UK offering in-patient programmes. There was concern around the data on Insight and MS asked that the pain team and Service Manager advise him of issues so he could raise these with Ruhi Youssefian in IM&T. Whilst the system could not give trends over a period of years RZ confirmed the number of GP referrals had increased significantly over the past 5 years. Since opening the books with the new consultant there had been a steep rise and JS added that a business case is being worked on for another additional consultant. The Trust is looking to be commissioned for highly complex specialist services MONTHLY REPORTS Patient Improvement Experience Committee report KH advised of an amendment whereby there had been 8 clinical complaints for the quarter but 23 complaints overall. With regard to the Patient Group visit to the Prosthetic Centre the committee noted that the Director for Estates and Facilities is working on an action plan to rectify the ventilation and other issues. Research and Development Report GE raised a concern regarding the unauthorised publication and MHRA inspection findings that RNHOH practices put patients lives at risk. IH clarified the position saying the study was not properly registered or conducted at this site however we are responsible for clinical behaviour of those who are given authority to undertake studies. The committee was

5 advised this was a previous radiologist who is now working in Auckland and this issue had been discussed at Executives. We now have control mechanisms to ensure this does not happen again ACUITY Tool re-audit BM confirmed this report related to a second review and the findings will be discussed at the Trust Board after comments from this committee. GB commented on the additional staffing cost of 374,864 which is identified as a nursing requirement for 12 nurses. Safeguarding Childrens Report BJ said that this report had been discussed at the Board earlier. He went on to advise that the Lead Nurse for Child Safeguarding was on sick leave which may create a weakness in the service. BJ and CW will discuss this outside the meeting and ensure nursing staff are aware but that she would attend the forthcoming Child Protection meeting Action: Camilla Wiley and Benjamin Jacobs to discuss the Child Safeguarding Lead, and Camilla Wiley to attend the forthcoming Child Protection meeting ROOT CAUSE ANALYSIS (RCAs) RCA62 Death on ABU GE briefed the committee on this case where a patient, who suffered a road traffic accident a year ago leaving him a complete C4 tetraplegic had been treated at Stoke Mandeville Hospital. He was referred to the RNOH for an outpatients appointment for his plexopathy and seen in the private patient pre-admission clinic by a locum physiotherapist. No referral was made to the spinal cord injuries physiotherapist or any other spinal cord multi disciplinary team. He was admitted from Stoke Mandeville Hospital to Ian Monro Ward on 29 th May. The planned surgery was uneventful and his return home was only delayed due to alterations being made to his shower at home; so he was staying for hotel reasons. His condition started deteriorating from 2 nd June although MEWS scores were still low. The on-call SHO referred to Outreach after reviewing an abnormal chest x-ray and the patient vomiting. He was transferred to ABU on 3 rd June where severe pneumonia with septic shock was diagnosed. He continued to deteriorate and had several cardiac arrests and died on 4 th June. The main contributory factors were a lack of specialist knowledge on the ward in caring for a spinal cord injury patient, and although the patient was becoming critical the low MEWS chart score did not pick up certain clinical indications that should have escalated his care. CW advised that the Matron for HDU has arranged specific orthopaedic courses for nurses and junior doctors; there will be two on-call doctors over the weekends and a formal handover process is now being carried out. It was also noted that RCAs are carried out on all cardiac arrests. The committee then discussed the suitability of some wards to treat certain patients conditions. Consultants often prefer the private ward environment but within our specialist hospital. Therefore the committee recommended that if a consultant brings a specialist patient to the Private Unit or the Childrens unit that they notify in advance the appropriate specialist group within the hospital. The meeting agreed that this subject be discussed further outside of the committee. Action: Geraldine Edge agreed to take ownership for the Action Plan Recommendation: consultants notify specialist MDTs within the RNOH when they are admitting a specialist patient to the Private Unit or the Childrens unit RCA52 Growth Rod-Action Plan RCA53 Delay in Theatres-Action Plan

6 These had already been discussed earlier in the meeting 8. TRANSFORMATION AND SERVICE DEVELOPMENT NICE Guidance Outstanding NICE Guidance there were none outstanding The committee noted the following NICE Guidance would be sent out for responses: Technology Appraisal Guidance: TA292, TA293 and TA294 Pharmacy to review and discuss at Drugs & Therapeutics Committee Clinical Guidelines CG167 Myocardial infarction with ST-segment elevation (July 2013) to be sent to Paul Gunning Interventional Procedure Guidance IPG457 Insertion of customised exposed titanium implants without soft tissue cover for complex orofacial reconstruction (July 2013) to be sent to A MacQuillan 10 UPDATE FROM EXECUTIVES MEETING CW and MS raised several key points from previous meetings. There are concerns over the escalation of morbidity procedures. CW said she was meeting with the Matrons to discuss. Possibly due to the increased activity and we will need a co-ordinator on a late shift. We will also need additional staffing for HDU to avoid using bank and agency nurses. There had been a problem with the temperature in the blood room although it seems there is now an air conditioning unit to maintain correct temperatures. As mentioned at the last committee we may need to manage with 50% less junior doctors. MS said we should have plans in place for different ways of working in case of a worst case scenario. The bed re-alignment has been put back to December MESSAGE FOR THE BOARD The key points from Clinical Quality Governance Committee for the Trust Board:- i ii iii iv Possible junior doctor shortages in October and the need to plan for different ways of working Bed-realignment project update Training regarding morbidity Policy expiry identification and delay in project delivery 12 ANY OTHER BUSINESS 12.1 Surgical Site Infection Surveillance MS referred to the attachments circulated from Public Health England (PHE) regarding our above national average rates for surgical site infection (SSI) surveillance relating to knees and spines. Data is collected in the major groups of spines, hips and knees. Our surgical data is benchmarked against data collected by PHE for surgical specialities for all UK hospitals. However, few hospitals cover the range of sub-

7 specialities that the RNOH surgeons undertake when examined by operational codes. If RNOH spinal surgery SSI rates are compared using spinal infection rates alone they are unremarkable. Scoliosis Research Society, Morbidity and Mortality database ranges for SSIs from 0.18%-5% and ours is 1.6% which does not give cause for concern In order to standardise the Divisional Reporting presentations AHG requested that an A4 page report should be prepared and circulated to the committee. Service Managers should work with the Clinical Leads to go through the data from Insight in order to prepare for the presentations. JS agreed to liaise with the relevant clinicians. Action: Jane Shental and Tara Argent to liaise with clinical leads in preparing a standardised report for circulation to the committee There being no further matters to discuss the meeting closed at 2.30pm Date and Time of Next Meeting Friday, 20 th September at pm Seminar Room 1