Apologies Mr Graham Crerar, Dr Andrew Evennett, Dr Michael Foxley, Ms Joanna Macdonald, Mr Bill Reid, and Mrs Catherine Stokoe

Transcription

1 CLINICAL GOVERNANCE COMMITTEE Highland NHS Board 3 February 2015 Item 3.4 Report by Sarah Wedgwood, Chair, Clinical Governance Committee The Board is asked to: Note that the Clinical Governance Committee met on 8 December 2014 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the consideration of the specific items detailed below. Note the items for discussion at the next meeting to be held on 10 February Committee Members: Ms Sarah Wedgwood, Chair Ms Elspeth Caithness, Staffside Representative Ms Caron Cruickshank, Superviser of Midwives/Maternity Services Quality and Safety Coordinator Dr Paul Davidson, Clinical Director, North & West Operational Unit Mr Mike Evans, Non-Executive Director Dr Michael Hall, Clinical Director, Argyll & Bute CHP (videoconference) Dr Roderick Harvey, Interim Medical Director Ms Heidi May, Nurse Director Dr Ken McDonald, Interim Associate Medical Director, Raigmore Hospital Dr Ian Scott, Clinical Director, South & Mid Operational Unit In Attendance: Dr Derek Brown, Lead Chaplain and Bereavement Coordinator (items 7 and 8) Mrs Alison Hudson, Lead Nurse, North & West Operational Unit (item 3) Mrs Mirian Morrison, Clinical Governance Development Manager Mrs Kate Patience-Quate, Lead Nurse, South & Mid Operational Unit (item 3) Ms Donna Smith, Project Manager Operations (item 2) Mrs Katherine Sutton, Divisional General Manager - Medical Division, Raigmore Hospital (item 3) Miss Irene Robertson, Board Committee Administrator Apologies Mr Graham Crerar, Dr Andrew Evennett, Dr Michael Foxley, Ms Joanna Macdonald, Mr Bill Reid, and Mrs Catherine Stokoe 1 ITEMS FOR DISCUSSION The items discussed at the meeting are noted below: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) Case Study Health Records Management Care of Older People in Acute Hospitals (OPAH) Complaints Performance Incident Management Review of Clinical Governance Committee Role and Remit Bereavement Services and Changes to Death Certification Process Spiritual Care Governance NHS Highland Annual Mortality Reviews Vale of Leven Hospital Inquiry

2 2 ITEMS FOR DISCUSSION AT NEXT MEETING ON 10 FEBRUARY 2015 Case Study Exception Reports/Emerging Issues from Operational Units NHS Highland Annual Mortality review Raigmore Hospital Complaints Performance Incident Management Screening Programmes Annual Report 3 CONTRIBUTION TO CORPORATE OBJECTIVES This performance report demonstrates how NHS Highland is achieving its corporate objective of ensuring that services delivered are of high quality and clinically effective. 4 GOVERNANCE IMPLICATIONS This performance report has a direct impact on clinical governance and demonstrates performance against responding to complaints, clinical effectiveness activity, patient safety and NHS Healthcare Improvement Scotland reviews. 5 IMPACT ASSESSMENT This report does not require impact assessment. Sarah Wedgwood Chair, Clinical Governance Committee 24 January 2015 Before commencing business, the Chair reminded the Committee that Michael Roberts and Alan Simmons had completed their terms of office and she again expressed her appreciation of their valuable input and support over the last three years. Arrangements were in hand to appoint two new public members. 2

3 CLINICAL GOVERNANCE COMMITTEE ASSURANCE REPORT 8 DECEMBER ) TOPIC: CASE STUDY FOLLOW UP The Committee received an update on the case study presented to the Committee at its meeting held on 29 April This incident had highlighted areas of non-compliance with procedures, delays in certain processes, lack of documentation in the patient s notes and issues relating to clinical communication and follow up of pathology reports and information contained in Immediate Discharge Letters (IDLs). There is a need for systems in place across the area, both in secondary and primary care, with the ability to track samples to ensure they do not get lost and the results of tests are promptly communicated and followed up. Consideration needs to be given as to how to minimise the risk of such incidents and systems failures occurring. There are significant issues arising from implementation of Phase 1 of the new Patient Management System (PMS) regarding data and reporting functionality which have delayed implementation of Phase 2, the clinical element that includes OrderComms the electronic ordering of tests. While it was felt OrderComms would address some of the issues, its functionality would require to be tested in terms of what level of mitigation against the risks it can provide. A range of actions has been taken in response to the incident. Among these is the development of a detailed pathology pathway with safety links built in to enable requests for tests to be tracked and followed through. Acknowledging that different areas will require different solutions, the Committee noted that some specialties have instituted systems for tracking samples and that further work is to be done to develop appropriate mechanisms across the Operational Units to address the issue. The Committee recommended a working group be established to undertake a systems-wide review and formulate proposals as to the processes to be put in place for tracking samples/following up test results. The review, which should encompass the primary care setting as well as acute hospitals, might consider the use of SCI Store and the aspiration to eliminate paper reports. An update on progress with this work to be submitted to the Committee in 6 months time. Action: Clinical Directors 3

4 2) TOPIC: HEALTH RECORDS MANAGEMENT The Internal Audit Report of November 2012 relating to the management of health records within NHS Highland made a number of recommendations, the majority of which were as a result of the lack of an area wide approach to this function. There is a risk of non-compliance with the requirements of the Public Records Scotland Act Following integration, NHS Highland also needs to consider its responsibilities in respect of social care records. Implications for health record management of the introduction of the new Patient Management System and the issues identified relating to data and data quality. Of particular concern are missing outcome codes and patients being lost to follow up. The Committee was assured of progress being made against the recommendations of the audit report and towards achieving compliance with the Public Health Records Scotland Act. An area wide Health and Social Care Records Committee has been established which covers those areas of social care for which NHS Highland is now responsible. The NHS Highland Records Management Policy has been updated to reflect current practice and complies with the legislative requirements of the Act. A Records Management Strategy has also been developed. Work is ongoing to develop standard procedures and training requirements. Key Medical Records Officers are working across Highland to ensure areas of poor practice are identified and addressed. Good progress is being made with the development of standard reports for managing health records. PMS functionality will enable patients who have not had a clinical outcome code applied to be identified and a report can now be run to monitor the position. The number of missing outcome codes has reduced substantially. An update on the position regarding missing outcome codes and follow up of patients to be prepared for the Committee. Action: D Smith 3) TOPIC: CARE OF OLDER PEOPLE IN ACUTE HOSPITALS (OPAH) Health Improvement Scotland (HIS) s scrutiny process has changed, the organisation now HIS visited NHS Highland on 18 November Overall this was a very positive visit An update on the roll out of the new nursing documentation and a progress report on the key 4

5 undertaking an annual inspection visit to each NHS Board to review the improvement methodology they have in place and the level of improvements made in two specific areas Infection Control and Care of Older People in Acute Hospitals (OPAH). Food, Fluid and Nutrition is a key OPAH workstreams. The HIS standards were reviewed and re-launched in October Consistency of approach is required across all areas including the community. There is significant work to be done around people s knowledge, skills and understanding of the malnutrition tool (MUST) and the documentation to be used. This is NHS Highland s top priority linking in with work around implementation of pilot inpatient documentation which goes live on 5 January Falls Prevention is another key OPAH workstream. Falls are the single most commonly reported patient safety incident in hospitals and are a focus of the Scottish Patient Safety Programme (SPSP) approach to reduce falls with harm in hospital. There has been an increase in the rate of all reported falls during March August 2014, although no significant rise in falls with harm has been demonstrated. The increase in all reported falls may be due to an increased focus on falls and increased levels of reporting. In addition, falls in the care home setting are now being reported through the Datix system. Other factors such as increasing frailty of the population, cognitive status and length of stay in hospital could also be impacting on the position. during which we presented our improvement methodology (HQA and RPIW processes) and discussed the key OPAH workstreams. Positive feedback was also received regarding HIS s unannounced visit to Lorn & Isles Hospital. A detailed action plan is in place to achieve a coordinated and consistent approach to the effective delivery of food and fluid in NHS Highland hospitals. The Menu Planning Group is to be reconvened and will link with the Catering Review Group to ensure menus are nutritionally analysed and reviewed on a regular basis. Education and training are being provided for staff to ensure compliance with nutritional assessment and care planning to meet each patient s needs; this includes using the MUST tool to record each patient s weight within 24 hours of admission. The SPSP falls prevention bundles are being tested and integrated into NHS Highland s approach to preventing falls in the inpatient setting. A range of initiatives and improvement work is underway. Some areas in Argyll & Bute have implemented unscheduled care pathways with the aim of reducing hospital admission and inpatient falls. Pilots in areas of North Highland have evidenced a reduction in the number of people who have had a fall being taken to A&E Departments. It is recognised that a high percentage of people who have suffered a fall may have cognitive impairment or dementia. Linking dementia and falls work more closely will ensure best practice in the care planning and clinical management of patients to reduce the risk of falls. OPAH workstreams to be submitted to the Committee in 6 months. Action: H May 5

6 Health Improvement Scotland carried out unannounced OPAH inspections in Belford and MacKinnon Memorial Hospitals on 24 June A number of areas were identified for improvement in both hospitals, mainly in relation to nursing documentation. There is also a need for a programme of learning and development in person centred care planning to support the delivery of individualised care and care planning. Another area identified for improvement was nutritional assessment and the consistent use of the cognitive impairment assessment tool on admission to hospital. While there were areas for improvement in both sites the HIS inspection also identified areas of strength, and patient feedback was generally positive. Good progress has been made in relation to nursing documentation. The revised documentation which goes live in January 2015 includes a robust care planning template. Education and training sessions are being delivered focusing primarily on care planning and identifying the needs of individuals. Each Operational Unit has its own OPAH Group which feeds into the Patient Centred Care Experience Group, and progress against each of the OPAH workstreams is monitored and learning shared. 4 TOPIC: COMPLAINTS PERFORMANCE The Committee received the complaints report detailing current performance against the revised response time targets for simple and complex complaints. The report indicated a deteriorating position, NHS Highland performing less well than other NHS Boards. The main themes of complaints across Scotland relate to staff attitude, treatment, waiting times and environment/domestic issues. Within Highland there are staffing capacity issues in terms of the time required to investigate and respond to complaints, some of which are very complex. An increase in the number of complaints submitted to the SPSO was also noted, although not all these complaints were upheld. A range of measures is being taken to improve the position and achieve prompt, local resolution of issues raised. The complaints resource pack has been revised. Work is ongoing to improve the quality of response letters and ensure these are timeously issued. Further discussions to take place with the Operational Units regarding systems and resources required to more effectively assess and manage complaints, both simple and complex. In addition, complaints procedures and processes in other Boards to be explored with a view to identifying potential learning points. Action: M Morrison 6

7 There is a need to identify the reasons for the increase in the numbers and types of complaints received and address the issues accordingly. Is there learning to be had from the better performing Boards? There are different legal requirements and procedures to be followed in respect of complaints relating to social care. 5) TOPIC: INCIDENT MANAGEMENT PERFORMANCE The Committee received the incident management performance report detailing activity and details of major and extreme incidents in the Operational Units in Quarter 2. All incidents are now logged on Datix and shared with the Operational Units. A concern was raised in relation to the number of outstanding incidents on the system. While these are mainly lower level incidents it is important that they are timeously dealt with and the loop closed. A query was raised in relation to the impact of incidents on patients. The Committee would wish to be assured that consideration is being given to this matter and that issues identified are being addressed. The Adverse Events Policy and Procedures have been updated and published on the Intranet so that staff can readily access it. Resource materials have been developed to support staff investigating adverse events. A workshop will be held in January 2015 to promote the new materials and agree a consistent approach. Status reports on outstanding incidents are sent to Operational Units on a monthly basis highlighting the need for timeous review. An automatic feedback function is now operational on the Datix incidents module which automatically generates an back to the reporter of the incident once the incident has had final approval. A series of dates has been arranged for Datix incident training. With regard to ongoing work to improve performance, a maternity dashboard has been developed and reconciliation meetings are being piloted within the Midwifery Service with the aim of addressing potential complaints at the earliest possible stage. Recommend a briefing on the Datix system be prepared for each of the Operational Unit Quality & Patient Safety Groups reinforcing the need to feed back to staff on incidents reported. Action: M Morrison 7

8 Detailed work is to be undertaken on pressure ulcers reported on Datix in relation to the grades of ulcers and where they are occurring. It was noted the numbers of grade 3 and grade 4 ulcers are reducing. The Committee received and noted the Scottish Government consultation document setting out proposals to introduce a statutory duty of candour for health and social care services. This would require providers of health and social care in Scotland to notify and support people affected by serious incidents. Agreed comments would be submitted on an individual basis. Action: Committee Members 6) TOPIC: ROLE AND REMIT OF CLINICAL GOVERNANCE COMMITTEE Following receipt of the Internal Audit Report on Clinical Governance, the Committee took the opportunity to review its role, remit and working arrangements to enable it to fulfil its core function and responsibilities in assuring itself of systems in place and quality and safety of patient care. The review to consider the information the Committee requires and its presentation, and how its agenda is structured, taking cognisance of its statutory responsibilities, for example in relation to its reporting committees. A number of suggestions were put forward as to the format for the Committee s agenda to ensure core topics are covered at each meeting. These included: A case study to be presented at each meeting. Exception reporting by Operational Units to bring relevant issues to the Committee s attention which would provide an audit trail of activity, actions taken, learning points and shared learning. Minutes of meetings of the Operational Unit Quality & Patient Safety Groups to continue to be received. Introduce an annual report system for the various reporting committees which would highlight exceptions and issues, Further discussion to take place outwith the meeting with a view to developing proposals on how the Committee functions going forward. Action: Chair / R Harvey 8

9 how they have been resolved or if they need to be escalated. Continuing input and support from the Clinical Governance Support Team in relation to complaints and incident management performance. The Chair to continue to attend meetings of the Operational Unit Quality & Patient Safety Groups. Annual meeting with Operational Units to discuss/agree priorities. 7) TOPIC: BEREAVEMENT SERVICES AND CHANGES TO DEATH CERTIFICATION PROCESS Development of bereavement services in NHS Highland to provide both emotional support to bereaved families and advice and information on practical issues following bereavement. Implications of changes to the Medical Certificate Cause of Death (MCCD), both for health professionals and the public. A medical review process has been introduced whereby a random sample of death certificates will be scrutinised to ensure they are in order and contain no administrative/clerical errors. A concern was expressed that the medical review process could potentially cause delays for bereaved families in making funeral arrangements. Work is ongoing to develop bereavement services. A Bereavement Officer has been appointed at Raigmore Hospital who will act as a single point of contact assisting both staff and bereaved people, and liaising with external agencies such as Registrars, Funeral Directors and the Procurator Fiscal. The Chaplaincy Department is offering staff sessions about loss and bereavement to raise their awareness and assist their understanding of this complex and sensitive area. The Committee received assurance that action had been taken to ensure relevant health professionals have been informed of the changes to the death certification process and have been provided with the necessary training. A Local Implementation Group has been established which will monitor the position and address any issues that emerge. A communication policy is being developed to Work to continue in developing bereavement services. Action: D Brown 9

10 help inform the public of the changes and explain the medical review process and its purpose. There is also a process for expedited review where appropriate, eg on religious/ cultural/compassionate grounds. Cases referred to the Procurator Fiscal will not be affected by these changes. 8) TOPIC: SPIRITUAL CARE GOVERNANCE To recognise spiritual care as a core and necessary part of health and social care delivery and embed it in mainstream activity. There are resource and capacity issues for Chaplains in relation to delivering spiritual care services. A Spiritual Care Strategy has been developed and an action plan is in place to implement the key workstreams Development of Chaplaincy staff and volunteers Working in the community Quality Training and Education Staff Support Further developments are planned. The Spiritual Care Strategy will be reviewed on an annual basis. The national guidelines that have shaped spiritual care in the past are currently being reviewed and a national delivery plan for Chaplaincy is being drafted. Ongoing activity to further raise awareness of, and embed spiritual care in everyone s practice to continue. Action: D Brown 10

11 9) TOPIC: NHS HIGHLAND ANNUAL MORTALITY REVIEWS The Committee received the Annual Mortality Review Report 2013 for Raigmore Hospital. As there was insufficient time for detailed discussion to take place, it was agreed to defer the report to the next meeting. The Annual Mortality Review Report 2013 for Raigmore Hospital to be included on the agenda for the next CGC meeting to be held on 10 February Action: Committee Administrator 10) VALE OF LEVEN HOSPITAL INQUIRY The report of the Inquiry makes 75 recommendations, 65 of which are for NHS Boards. What are the implications for NHS Highland and how will assurance be obtained that the recommendations of relevance to NHS Highland are implemented? A self assessment process against the recommendations is underway, led by the Control of Infection Committee. The self assessment is due to be submitted to Scottish Government by 19 January A copy of NHS Highland s response to be submitted to the Committee. Action: H May 11