The Scottish Ambulance Service Medical Directorate. Annual Clinical Governance, Risk Management and Patient Safety Report

Transcription

1 The Scottish Ambulance Service Medical Directorate Annual Clinical Governance, Risk Management and Patient Safety Report Mrs C Humphries, Chairman of the Clinical Governance Committee. Dr G Crooks, Medical Director. Without doubt the actions of the Crew saved the patient s life. This patient had minutes to live. our message of thanks to the Crew for the first class job they did, this account illustrates the importance of clinical judgement by the Ambulance Staff From an Interventional Cardiologist in Glasgow. 1

2 Contents Page Forward Pg 4 Introduction Pg 6 Introduction to the Scottish Ambulance Service Pg 7 Definition & Principles of Clinical Governance Pg 8 The Services Clinical Governance and Effectiveness Model Pg 10 The 2009 to 2010 Patient Experience Pg 11 NHS Quality Improvement Scotland Pg 14 Safe and effective care and services Clinical Risk Management and Critical Clinical Incidents Pg 17 Scottish Patient Safety Programme Pg 20 Infection Control Clinical Performance Reporting Pg 23 Clinical Audit & Improvement Pg 25 The Health, Wellbeing and Care Experience EMDC integration with NHS 24 Pg 26 2

3 Complaints & Commendations Pg 27 Assurance and Accountability Clinical Governance Work Programme Pg 28 Clinical Policies & Procedures Pg 29 Education and Training (Fitness to Practice) Pg 31 Research & Development Pg 32 Information Governance Pg 33 Conclusion Pg 34 Appendices Appendix A - Meeting dates, attendees and topics covered by the Committee Pg 35 Appendix B - Clinical Governance Work Programme 2009/ /11 Pg 37 Appendix C - Medical Directorate Structure Pg 39 3

4 Forward by the Chairman of the Clinical Governance Committee I am pleased to present this, my third Annual Report, on Clinical Governance within the Scottish Ambulance Service. As always, the past year has been both challenging and rewarding and the Committee is most appreciative of the commitment and dedication of our staff in providing safe and effective pre hospital care and transport. In a very busy year, the report attempts to record major achievements and developments in Clinical Governance and identifies where further work is being progressed. During the year the Service has appointed Divisional Clinical Governance and Quality Leads reaffirming the Service s commitment to the delivery of safe, effective and high quality clinical services. This stands us in good stead to support the delivery of the Scottish Governments emerging quality strategy. Our use of technology to establish the electronic patient report form and the delivery of the Data Warehouse Project is supporting the development of a suite of clinically focussed performance indicators, focussed on the outcome our patient treatment and care and further supporting patient safety. The Co-location of our Emergency Medical Despatch Centres (EMDC) in Cardonald and South Queensferry has led to improved communication and coordination of available NHS responses to individual patients. The Service was visited by the NHS Quality Improvement Scotland review team who looked at our clinical governance and risk management arrangements. Their report recognised the significant developments that have taken place over the past few years in the field of clinical 4

5 governance and risk management while presenting us with one or two suggestions for further developments. Christine Humphries May

6 Introduction The Clinical Governance Committee is one of the Service s three Committees of Governance, assuring the Board that the Service delivers safe and effective clinical care. As in previous years, it met four times in and its agenda topics are listed in Appendix A. During the year the Committee received reports from the Clinical Effectiveness Group, the Risk Management Steering Group, the EMDC Clinical Advisory Group, the New Ways of Clinical Working Group and, where appropriate, the Infection Control Committee. It also received ad hoc reports on a range of Governance issues. The purpose of this annual report is to outline progress in clinical governance requirements during the last year of operation of the Scottish Ambulance Service. Overall we are pleased to report that the Service continues to make good progress in maintaining and achieving improvement in the quality of the services that are provided. In particular we have continued to maintain good engagement with partner agencies, NHS24, Community Health (and Care) Partnerships and territorial Health Boards and these links will be fundamental to achieving the Government s Better Health Better Care: Action Plan. 6

7 Introduction to the Scottish Ambulance Service The Scottish Ambulance Service is a Special Health Board of NHS Scotland. It employs 4,300 staff across mainland Scotland and Islands with a budget of around 200 million. It is responsible for the pre-hospital care and transportation (where necessary), using aircraft and land vehicles, of patients to appropriate care facilities for circa 600,000 accident & emergency and 1.6 million nonemergency cases each year. The Service must also manage an annual rise in demand for both the Accident and Emergency and Patient Transport Services. The Service s current Clinical Mission is to: Save Lives Improve Health Reduce Hospital Admissions The Scottish Ambulance Service Board has undertaken an overall review of its Service Strategy. The process of developing a long-term vision to inform the new Service Strategy began in January 2009 and involved extensive consultation across the Service and with key external stakeholders. The strategy document was completed in September In addition, a review of Clinical Governance led to the Service introducing a new Medical Directorate with dedicated senior clinical & governance staff in the fiscal year (Appendix C). 7

8 Definition and Principles of Clinical Governance The purpose of clinical governance is to ensure that patients receive the highest quality of care possible, putting each patient at the centre of their care. This is achieved by ensuring that those providing services work in an environment that supports them and which places safety and quality of care at the top of the organisation s agenda. While the term clinical governance may be relatively new, the concept is not, as it involves making sure that healthcare is safe and effective and that the public are involved In Scotland in 1997 the concept of clinical governance was introduced. The government white paper Designed to Care stated that the objective of a National Health Service designed for patients is to provide better services for them in ways that are responsive to their needs and wishes. Good quality health care delivered consistently and to a high standard must be a key objective of the NHS in Scotland (Scottish Office, 2007) Clinical Governance has been defined by the Government as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish. For us this means making sure that systems are in place for maintaining and improving the quality of treatment and care we provide and that this is encouraged and supported in everything we do. The principles of Clinical Governance are fundamental to our work and underpin the core values that are central to our strategic direction. 8

9 Principles of Clinical Governance Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and safeguarding high standards of care and services, NHS Quality Improvement Scotland (2005). These standards are:- Safe care and services all clinical and non-clinical risks are assessed and mitigated. Effective care and services the efficiency of interventions and processes are continuously assessed to ensure they promote better patient outcomes. Clinical governance is a powerful tool the main elements of which are risk management, clinical effectiveness and patient focus. These elements are embedded in the seven pillars of clinical governance which is reflected in the Temple Paradigm below. 9

10 The Service s Clinical Governance & Effectiveness Model P a t i e n t J o u r n e y y 10

11 The 2009 to 2010 Patient Experience Without doubt the actions of the Crew saved the patient s life. This patient had minutes to live. If the Ambulance Crew had followed protocol instead of their clinical judgement and taken the patient to his local hospital, he would now be dead. our message of thanks to the Crew for the first class job they did, this account illustrates the importance of clinical judgement by the Ambulance Staff From an Interventional Cardiologist in Glasgow. Social and market research was commissioned by the Scottish Ambulance Service (SAS) to undertake the sixth consecutive annual wave of patient experience research. The aim of the research was to gain insight into patient attitudes, opinions and experiences of the service provided by the SAS. Sample Size. For the quantitative research, 938 telephone interviews were conducted with patients who had used the SAS within the last 12 months. 475 were Accident & Emergency patients and 463 were Patient Transport Service Patients. An equal number of respondents from the five operating divisions was ensured. Results Accident and Emergency Patients Total satisfaction with time taken to reach patient:- 90% (range across 5 Divisions from 87% to 93%) 11

12 Overall satisfaction with services has remained high - 98% For A&E patients, care received from ambulance staff and professionalism of ambulance staff were both high at 93% and 94% respectively rating it very good Only 3 respondents were dissatisfied with service received (compared to 5 in 2008). Reasons for dissatisfaction were: - ambulance took too long (1 respondent) - sent the wrong kind of paramedic (1 respondent) - there was no need for an ambulance (1 respondent) Patient Transport Service Patients For PTS patients, 92% rated the professionalism of the ambulance staff as very good 94% of PTS patients were satisfied with the time of the ambulance s arrival at their home 94% were also satisfied with the ambulance s time of arrival at the hospital Overall Satisfaction:- 95% All Patients Translation Service Of the 10 respondents who had used the translation service, 9 described it as very good. 12

13 If you have special needs, did the service meet these needs on this occasion Fully meet your needs - A&E 86% PTS 81% Mostly meet your needs - A&E 13% PTS 16% Partially meet your needs - A&E 2% PTS 1% Did not meet your needs at all - A&E 0% PTS 2% How would you describe the service (All patients) Very Good 90% Quite Good 0% Neutral 10% Quite Poor 0% Very Poor 0% 13

14 NHS Quality Improvement Scotland The Service has just completed the second review by NHS QIS against the National Standards for Clinical Governance and Risk Management where it achieved its best ever score. These standards are extensive and cover much of the clinical processes and guidelines that we use. The results provided an important focus for the Clinical Governance Committee in seeking assurance that requirements are being implemented across the Service. Although the Service achieved a very high standard, some areas of improvement were identified and an action plan has been agreed to address these. This is shown overleaf. 14

15 NHS QIS Clinical Governance and Risk Management Review Action Plan Author Sarah Kilday 05/01/2010 Distribution Status CGC / Audit Committee / RMSG Action Point No. Date Action Raised Description of Action Point Action Owner Status / Latest Update Target/ review Date Action for all Areas Committee Reporting Structure / Quality Assurance Open / Complete Formalise the monitoring of the effectiveness of systems (level 3) across the Service. 1 31/10/2009 Monitoring of the Effectiveness of Risk Management systems to be conducted in a formal and structured manner. 2 31/10/2009 Formal Review of Risk Management strategy to be conducted prior to publication of strategy. 3 31/10/2009 Benchmark risk management arrangements. Risk Management Effectiveness of RM Systems S. Kilday reviewed by the Board at Risk Management workshop. Audit to conducted by Delloitte's S. Kilday July 2010 Ongoing with Scottish Datix S. Kilday Users Group. Emergency and Continuity Planning 4 31/10/2009 Improve Document Control on the Services Emergency Plan to show review dates and changes made. Clinical Effectiveness and Quality Improvement 5 31/10/2009 All Divisions to have local groups that consider clinical effectiveness which feed into the National Clinical Governance Group for consistency. P.Gowens / Clinical Leads Ongoing Quarterly review at NCGG 6 31/10/2009 Patient Safety program to be tailored to meet the needs of the Service. 7 31/10/2009 Examine equality monitoring procedures to establish the best route to incorporate religion/belief and sexual orientation strands. 8 31/10/2009 Evaluative discussions to be formalised in a structured manner to evidence monitoring of current systems. 9 31/10/2009 Carry out a structured review of the effectiveness of the arrangements in place for equality and diversity in order continuosly improve arrangements. No actions identified in 2c or Standard 3. Standard 1 - Safe and Effective Care and Services 27/01/2010 RMSG/CGC/Audit Complete 01/08/2010 RMSG/CGC/Audit Open 31/03/2010 RMSG/CGC/Audit Open M Herriot Ongoing 31/03/2010 Resilience Committee Open Standard 2 - The health, wellbeing and care experience Access, Referal, treatment and discharge P.Gowens / G Crooks Ongoing Quarterly review at NCGG Equality and Diversity Utilise existing system for A. Tobin reporting on these strands, 02/04/10. Log outcomes following 1-1 meeting with Equalities Manager A. Tobin and Head of Personnel, 04/02/10. Requested that Independent auditors carry out an audit in this A. Tobin area of work for 2010/11, 04/02/10. Standard 3 - Assurance and Accountability Clinical Governance Committee Clinical Governance Committee Open Open 01/06/2010 Staff Governance Open 01/06/2010 Staff Governance Open 2010/2011 Staff Governance Open 15

16 The results shown below provide a comparison to the previous visit in 2006 STANDARD AND CORE AREA 06 Score 09 Score Standard 1 Risk Management 4 4 Emergency and Continuity Planning Clinical Effectiveness and Quality Improvement Standard 2 Access, Referral, Treatment and Discharge 4 4 Equality and Diversity 2 2 Internal Communication 3 4 Standard 3 Clinical Governance and Quality 4 4 Assurance Fitness to Practice 4 4 External Communication 3 4 Performance Management 4 4 Achieving the levels Level 1 - Development All key elements of arrangements must be already developed and signed off by the relevant committee/group. Level 2 - Implementation Arrangements largely rolled out across the organisation. Training largely completed. Staff using system. Regular operational management reports discussed by appropriate committee/group Level 3 Monitoring Outcomes monitoring not operational monitoring structured approach to evaluation of the effectiveness of the arrangements. Regular reports discussed by appropriate committee/group. Level 4 - Reviewing Using level 3 information to make changes to improve arrangements. Continuously reviewing and improving the arrangements. A cross section of staff and non-executive directors from the Service have also participated as reviewers for NHS QIS on the Clinical Governance and Risk Management standards. 16

17 Safe and Effective Care and Services Clinical Risk Management & Critical Clinical Incidents Achieved level 4 (reviewing) for risk management in the Clinical Governance and Risk Management (CGRM) standards 2009/2010. The Service has a Strategic Risk Management Plan, Policy and Incident / Accident Reporting Procedure for , which is reviewed annually. Risk Management within the Service is managed through a software system called Datix, which encompasses Incident Reporting, Risk Registers, Claims and Complaints. Each Division, Department and Project owns a risk log where risks are categorised into sub categories, including clinical risk, which are presented to the Clinical Governance Committee. Each identified very high risk within the Service is escalated to the Corporate Risk Register. During 2009/2010 the Board undertook its annual risk management session where it prioritized and identified new risks for the coming year and reviewed the effectiveness of the systems in place for risk management. The Risk Management Steering group also formed part of the Senior Management Team at the beginning of 2009, following a review of the current group. This has helped to further embed risk management into the culture of the Service by engaging with a wider group of staff. The following information gives an insight into the rating for clinical risks across the service, types of Critical Clinical Incidents reported and how we managed these incidents in the period

18 Risk by Risk level (current) 38% HIGH LOW MEDIUM 56% 6% The above graph demonstrates that the majority of Clinical Risks within the Service are rated as High (56%) with no very high clinical risks. We continue to support staff who report incidents and promote a fair and open culture" through our Risk Management Strategy. We undertake root cause analysis of all very high incidents and any incident that merits such a level of investigation - to ensure we discover the fundamental learning necessary and that it is communicated rapidly across the Service and where necessary beyond. 18

19 The information below shows the clinical incident statistics. Clinical Incidents by Incident date (Month and Year) Descriptor The graph above shows that since 2004 the clinical incidents have steadily increased, the peak in 2008 was due to the introduction of the web-based incidents reporting system. Top 5 Incidents - Financial Year Comparison /08 08/09 09/ Equipment Related/Failure Fall / Trip/ Slip Response Related EMDCRelated Excessive work load/ Fatigue/ Lone Worker Descriptor The above graph demonstrates that equipment related failures were the most commonly reported incident in 2009/2010 and this has increased in the last three years. The main reasoning behind this is staff reporting issues with Service issue thermometers. Investigations are being undertaken and a new thermometer is currently being piloted. 19

20 Scottish Patient Safety Programme The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland s health care leaders NHS executives, QIS experts, clinical professionals, civil servants, and more all aligned toward a common vision of making Scotland a safer nation from the viewpoint of health care. Although not explicitly included, the Scottish Ambulance Service has taken the opportunity to adopt the model for improvement and apply it to a number of quality projects. Healthcare Associated Infection (HAI) continues to be of major national importance and reducing the risk of HAI to both patients and staff is a high priority for the Service. The Infection Control Team produce an annual infection control work programme which addresses the national HAI agenda to include: Scottish Government Health Department (SGHD) HAI Task Force Delivery Plan , HAI Action Plan (Aug 2008), HAI elements of the Scottish 20

21 Patient Safety Programme, National Hand Hygiene Campaign and NHS Quality Improvement Scotland HAI Standards. The annual programme also addresses service issues based on audit findings, and risk assessment. The programme is approved by the Infection Control Committee (ICC) and the Chief Executive and endorsed by the Clinical Governance Committee and the Risk Management Steering Group. Further to the annual work Programme SGHD published an HAI action Plan in August 2008 for action by Boards. The Service has completed all actions relevant to the Service. The Service has implemented the requirements of the National Cleaning Services Specification (NCSS) and monitoring framework in all stations covered by Lothian and Greater Glasgow and Clyde Health Board areas. Cleaning and auditing is completed under contract by local health board staff. The Service will begin formally monitoring all other stations to the National Cleaning Services Scotland standard during financial year 2010/11, to this end 3 additional staff have been recruited and trained in the necessary skills to implement the monitoring framework across the Service. The findings of the National Cleaning Services Scotland audits will be reported monthly to Health Facilities Scotland who will include these in the quarterly compliance reports that cover the whole of NHS Scotland. The Infection Control Manager produces a HAI report for submission at every Ambulance Service Board meeting which currently meets bimonthly. 21

22 The Service s internal infection control team now comprises: Infection Control Manager Infection Control Advisor Hand Hygiene Co-ordinator 3 NCSS Auditors This represents six whole time equivalents. In addition to this there are three regional Health and Safety advisors and administrative support that equates to approximately one additional WTE. The Healthcare Associated Infection (HAI) element of the Scottish Patient Safety Programme is being addressed by the National Hand Hygiene Campaign work stream, alongside the Service s local hand hygiene audit programme - and the implementation of the National Cleaning Standard Specifications (NCSS) and monitoring framework. Over and above this the Service has developed and implemented a care bundle for the insertion of peripheral vascular catheters (PVCs). The care bundle is aimed at ensuring that evidence based practice is applied and aligns to the PVC maintenance care bundles used in hospitals. 22

23 Clinical Performance Reporting During 2007, we successfully implemented an innovative electronic reporting system, using cab-based technology. The system continues to be developed and improved, with 46 new screens and many improved features, such as clinical decision-support tools, inclusion of automated Scottish Early Warning System (SEWS) reporting, further clinicalguideline support, and ethnicity/disability reporting. The electronic system considerably altered the method of clinical performance measurement and now provides the Service with the largest live pre-hospital care database in Europe. This major investment in our ability to record, analyse, interpret and report clinical performance will continue to develop and inform our understanding of pre-hospital treatment and care and its patient outcomes. Plans are in place to further develop the system, including: Access to the Emergency Care Summary has been successfully trialed. This is an electronic record of the patient s medication and allergies held by the patient s GP. Having access to this information will mean that staff will be able to prepare before arrival on scene, thereby improving diagnosis and treatment on arrival. It is anticipated that this will go live during Summer The Service has been able to link its clinical data to hospital systems. In Ayrshire, emergency vehicles automatically transmit records to the receiving unit. This allows clinicians to prepare for the arrival of a patient including the provision of specialist staff and equipment. It also links SAS data into the Scottish Care Information national system. Further development of this system is currently underway. 23

24 Use of our Midash Clinical database has been further expanded, to allow improvement and audit use by locality team leaders. Training has been undertaken in all areas, and local, station-based improvement drives are ongoing. This has seen further, significant improvements in our compliance with reporting procedures. The Midash system has now been superseded by the introduction of the data Warehouse, giving us the most advanced clinical data/clinical Performance Indicator system in Europe. This, coupled with the local teams already using clinical performance data to encourage continuous improvement, puts us in an enviable position for future reporting and performance. 24

25 Clinical Audit & Improvement Items including substance abuse, stroke, road accidents, burns, respiratory illness, convulsions and diabetes were among the conditions audited during the year. In each case, there was good evidence of clinical improvement and benefit to patients. During the year local Team Leaders received audit training to allow greater ownership of clinical audit, at a local level. The ability of local staff to evidence performance improvement supports and encourages local staff to continue to focus on safe and effective care and generate further improvements. Compliance with clinical reporting procedures was strengthened during the year. Instances of staff over-riding the need for Diagnostic Codes ceased altogether by March Further improvement to the clinical reporting system was seen, with the first electronic linkage of pre-hospital data to hospital systems in Ayrshire. It is intended that this is developed further across the Service as Health Boards make linking to their data possible. A further trial saw SAS clinical data linked remotely to Ninewells Hospital data, using our clinical database. This should allow retrospective audits to focus on outcomes in the near future. Formal audits of Air Wing activity have shown the maintenance of, or improvement to, the clinical performance from all resources. 25

26 The health, wellbeing and care experience Emergency Medical Despatch (EMDC) Integration with NHS24 The Scottish Ambulance Service (SAS) and NHS 24 have recently become co-located on three sites in Cardonald, South Queensferry and Inverness, to fully support joint working wherever possible. The main benefits of an integrated approach are around developing shared systems and clinical best practice in telephone triage and resource deployment. The introduction of Paramedics into the EMDCs has added an additional level of clinical triage to enhance the patient experience and sharpen decision-making. The development of a shared clinical triage tool is being sponsored by Scottish Government and is being led by NHS24 and the Scottish Ambulance Service with project support to clinicians from both organisations. A common system of triage has potential benefits for use beyond the SAS and NHS 24 and may be used by other parts of the NHS including colleagues in out of hours and Accident and Emergency services. The caller will be directed to the safest and most appropriate care pathway depending on the nature of their individual need, no matter where they choose to access care. 26

27 Complaints & Commendations Complaints provide useful information from the perspective of service users, their carers, families, friends, and from the public about the quality of service we provide, including the standard of clinical care, staffing and resource issues. In order for the Service to use complaints as a valuable development tool, complaints data and reporting is shared widely throughout the organisation. During late 2009/10 the Complaints process was reviewed with views sought from patients and staff alike. It was recognised that the current process needed to be streamlined. A recommendation as part of this review was to look at all complaints, concerns, comments and compliments as Patient Feedback and grade them according to clinical risk and patient safety. Responses would be more proportionate and clinical issues would be more effectively channelled via the Clinical Governance structure. The review was presented to the Clinical Governance Committee and approved in early 2010 and a pilot is due to take place with a view to full implementation across the Service during 2010/11. For 1 April 2009 to 31 March 2010 the Service received 559 compared to 403 complaints the previous year. The Service received 456 compliments and commendations for the period 1 April 2009 to 31 March 2010 compared with 226 the year before. 27

28 Assurance and Accountability Clinical Governance Work Programme The Clinical Governance Committee approves an annual work programme, drafted in the early part of each financial year. This remains flexible to accommodate new issues and changing priorities. (Appendix B) The new Medical Directorate (Appendix C) is supporting implementation and development of the Service s clinical framework and strategy to ensure the delivery and improvement of safe and effective patient treatment and care where both case and skills mixes are changing. Working closely with the education and training department to ensure that our staff have the clinical education, training and equipment, along with clinical support with robust clinical governance in place to ensure our patients receive the highest standards of patient care Achievement and performance against the new suite of clinical indicators and clinical HEAT targets. New working arrangements with NHS24, including the development of shared triage tools and clinical decision support. 28

29 Clinical Policies and Procedures The Service continues to take an active part in the development of guidelines through research and audit, and by participating in the Joint Royal College Ambulance Liaison Committee (JRCALC) guideline development group. Eight new guidelines were implemented during the year 2009/10. We have implemented various initiatives in line with SGHD s Living & Dying Well Project Eight staff were released for two months by the Service, to communicate our End of Life Care Plan. During this time, 3,000 internal staff, from all disciplines, were given hands-on input. Additionally, contact was also made with 90 varying stakeholder groups. The Service has been instrumental in developing a National resuscitation policy (DNACPR), the first of its kind in the UK that will ensure all our operational staff can follow a single, effective policy irrespective of the Health Board area in which they operate. Trials have been conducted that demonstrated transmission of the General Practitioner Palliative Care Summary directly to vehicles en route to specific patient groups. It is anticipated that this will become fully operational during summer A new Palliative Care policy is currently under development. Early data from the recently launched, unique, ICECAP (Informed Continuous Education on Cardiac Arrest for Ambulance Personnel) project was submitted to the Faculty of Pre-hospital Care Scientific 29

30 Conference. This Edinburgh-based research is a novel project, the first of its kind in the United Kingdom. We know Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality and severe neurological disability. Survival from OHCA depends on good quality cardio-pulmonary resuscitation from Emergency Medical Services personnel. The time on the chest and interruption time for defibrillation have recently been shown to be crucial to survival. A retrospective study of quality control and clinical performance has allowed feedback to crews after their resuscitation attempts has been carried out on the quality of their Cardiopulmonary Resuscitation (CPR). The information in this study was pivotal in informing Defibrillator re-procurement and provides a good example of clinical effectiveness in action. 30

31 Education and Training (Fitness to Practice) Realising our Potential A Strategy for Learning was launched in response to the Service Strategic Framework Working Together for Better Care. This sets out not only the direction for Education and Professional Development but also for Leadership and Management Development. Building on the strength of our Health Professions Council approved programmes we have further developed the essential link between the learning environment and clinical practice. These clinical developments will be supported through re-procurement of the Education and Professional Development Department and the introduction of new roles including an Educational Governance Manager and Professional Development Advisors. This will provide the opportunity for robust clinical governance of the standards applied within education. The Education and Training department has established a clear link with the Medical Directorate to ensure a collaborative approach to the development and introduction of new equipment and clinical procedures. Notably this has included the introduction of Laryngeal Mask Airways and continuing focus on sustainable improvements in the management of cardiac arrest. 31

32 Research and Development We continue to collaborate with a number of Higher Education Institutes and Ambulance Services to ensure we participate in research essential for planning new services and to ensure we continue to provide evidence based clinically safe practice. In particular we have a close relationship with the Nursing, Midwifery and Allied Health Professions Research Unit at Stirling University where we have Clinical Paramedic Researchers permanently based or on rotation. All research proposals or research projects undertaken by the Service follows accepted research practice, particularly in areas of ethical approval, Caldicott approval and Research Governance standards. These standards are set by NHS Quality Improvement Scotland and assessed by the Scottish Chief Scientists Office. The Clinical Governance Committee receives regular reports on any proposed or active research projects. The Service Research and Development profile has continued to increase over recent years and we are about to participate in a Warwick University, multi million pound, UK research project into a specialist medical device used in cardiac resuscitation. We also have a research paramedic seconded to Helicopter Emergency Medical Service (HEMS) and another to undertake research into pre hospital diabetes care, fully funded by Diabetes UK. Currently the Service is also part funding a PhD research fellow at Stirling University. 32

33 Information Governance Prior to April 2009 Information Governance (IG) was included in the Clinical Governance framework with responsibility and oversight vested in the Clinical Governance Committee who reported on IG activity as part of the Clinical Governance Annual Report. Later in 2009 it became apparent that the prevailing arrangements for Information Governance could not be sustained if the Service was to meet its statutory and organisational obligations and an Information Governance Manager was appointed to consolidate all its disparate elements under the one banner. This resulted in an Information Governance strategy being developed and approved which included the requirement for the IG Manager to produce an annual Information Governance report separate from this one. The strategy also shifted oversight of IG to the newly formed Information Governance Committee, which will review and approve their Annual Report in due course. 33

34 Conclusion None of the above would have been possible without the professionalism and dedication of men and women in the front line and their commitment to doing the best possible job, round the clock, in all weathers and environments, whilst facing significant health and social challenges and continuing service change. We believe that effective clinical governance is at the heart of safe and effective patient care and this report describes some of the ways, we are working together to do better, in order to ensure that we learn and share experience from our successes and mistakes. Patients are at the heart of our work and it is encouraging that despite significant and continuing changes in their expectations and how we deliver services, the number of complaints and adverse incidents we deal with, remains low and patient satisfaction levels generally high. 34

35 Appendix A Date Expected Agenda Item Lead Agents Action Required Standing Items as per quarterly agenda As per agenda As required Specific agenda items Medical Directorate Development Update G Crooks Verbal Update/ specific Papers New Ways of Clinical Working Update Clinical KPI Development G Crooks Verbal Updates/Specific papers Clinical Audit Work Plan R Lawrenson Verbal updates/ Specific papers Complaints & Recommendations K Lowson Summarised quarterly table and report Clinical Performance G Crooks Standard Board style report Infection Control S Rogers Verbal Updates/Specific papers Better Health Better Care Action Plan Update G Crooks Verbal Updates/Specific papers Benchmarking Report R Lawrenson Verbal Updates/Specific papers Clinical Leadership Programme P Gowens Verbal Update/specific papers QIS Clinical Governance and Risk Management S Kilday Presentation Date Expected Agenda Item Lead Agents Action Required Standing Items as per quarterly agenda As per agenda A required Specific agenda items New Ways of Clinical Working Update B Mason Verbal report/papers Scottish Ambulance Service Submission for QIS Review S Kilday Verbal updates/ Specific papers Complaints & Recommendations K Lowson Summarised quarterly table and report Child Protection and Vulnerable Adults B Mason Verbal report/papers Staffordshire Report Update B Mason Verbal & or paper on action points Clinical Performance G Crooks Standard Board style report Clinical Governance Committee Annual Report Update P Gowens Verbal Updates/Specific papers Clinical Governance Internal Audit Report Auditors Verbal Updates/Specific papers Clinical Audit Work Plan R Lawrenson Verbal Updates/Specific papers Health Associated Infection Action Plan S Rogers Verbal Updates/Specific papers Date Expected Agenda Item Lead Agents Action Required Standing Items as per quarterly agenda As per agenda As required Specific agenda items New Ways of Clinical Working Update B Mason/P Gowens Verbal report/papers Clinical Performance G Crooks Standard Board style report Clinical Audit and Benchmarking Report R Lawrenson Verbal updates/ Specific papers Complaints & Recommendations K Lowson Summarised quarterly table and report Clinical Triage Development G Egan Verbal Updates/Specific papers Developments in the management of MI D Fitzpatrick Verbal Updates/Specific papers Health Associated Infection Annual Report and Update S Rogers/ S Wilson Verbal updates/ Specific papers Clinical Governance and Quality Systems Development G Crooks Specific papers Clinical Governance Work Plan P Gowens Verbal updates/ Specific papers Research Update B Mason Verbal Updates/Specific papers Expected Agenda Item Lead Agents Action Required Standing Items as per quarterly agenda As per agenda As required Specific agenda items Work Plan and Progress Report P Gowens Verbal updates/ Specific papers Underpinning Report P Gowens Verbal updates/ Specific papers Complaints & Recommendations K Lowson Summarised quarterly table and report Inter-hospital Transport Update C Kerr Verbal updates/ Specific papers Remote & Rural Strategic Options Update C Kerr Verbal updates/ Specific papers Clinical Performance G Crooks Standard Board style report Better Heart and Stroke Care Action Plan C Kerr Verbal Updates/Specific papers Child Protection B Mason Verbal Updates/Specific papers Internal Auditors Reports Auditors Verbal &/or paper See and Treat Update B Mason Verbal &/or paper 18th February th May th September th November 2009 The Committee expect to receive the latest available minutes from the Clinical Effectiveness Group, Patient Safety Group, R&D projects, Violence working Group etc. Note on paper reports these reports should follow Service best practice guidance (available on Samson) and where appropriate kept to a single double-sided page of A4. More extensive reports & audits should follow the Deloitte report style. Paper copies of presentations should also be made available prior a meeting. All must be available to the Committee Secretary at least 14 working days prior to meeting date. 35

36 6 th May 2009 Christine Humphries (Chair of Committee and Non Executive Director), Suzanne Dawson (Non Executive Director), David Garbutt (non Executive Director) David Nelson (Patient Representative) and Andrew Richmond (Non Executive Director). 9 th September Christine Humphries (Chair of Committee and Non Executive Director), Suzanne Dawson (Non Executive Director), Theresa Houston (Non Executive Director), David Nelson (Patient Representative).and Andrew Richmond (Non Executive Director) 4 th November Christine Humphries (Chair of Committee and Non Executive Director), Suzanne Dawson (Non Executive Director), Theresa Houston (Non Executive Director), David Nelson (Patient Representative), and Andrew Richmond (Non Executive Director). 17 th February Christine Humphries (Chair of Committee and Non Executive Director), Theresa Houston (Non Executive Director), David Nelson (Patient Representative) and Andrew Richmond (Non Executive Director). 36

37 Appendix B 2009/2010 Clinical Governance Work Plan - Action Tracker Author Distribution Status Paul Gowens Clinical Governance Committee Action Point No. Date Action Raised Description of Action Point Action Owner Open / Discharged Clinical Effectivness 1 06/07/2009 Review of STEPWISE approach to airway management SAD - EET - HAI P.Gowens J Burnham Open 2 06/07/2009 National Morphine Audit Robin Lawrenson Open 3 06/07/2009 Review of Tempurature Monitoring B.Mason Open 4 06/07/2009 Develop and Implement clinical advice hub in EDMC's Gerry Egan Open 5 06/07/2009 AMPDS outcome review Gerry Egan Open 6 07/07/2009 Research- LBBB- See and Treat- Diabetes- D Fitzpaterick Open 7 08/07/2009 Medicine Pouch roll out Gerry Egan Open 8 09/07/2009 Development of the Electronic Patient Record Robin Lawrenson Open 9 06/07/2009 W Mason/ Allan PRU Manual Shields/Gerry Egan Open 10 06/07/2009 Skills vs Case Mix Review - ECP D tough Open 11 06/07/2009 Review of Wound Glue Gerry Egan Open Risk Management 12 06/07/2009 Action Plan against CGRM - PS standards 1,2,3 S Kilday Open 13 07/07/2009 Development of Clinical Advisor role in EMDC Gerry Egan Open 14 06/07/2009 SEWS - Reduction of exceptions for see and treat D Milligan Open 15 06/07/2009 Development of pro-active Trigger Tools for clinical adverse incidents D Milligan Open 16 06/07/2009 Devlopment of Call streaming process with NHS 24 Gerry Egan Open 17 06/07/2009 Pandemic flu planning and arrangements Gerry Egan Open 18 06/07/2009 Implementtation and Audit ot PVC Bundle P Gowens / Susan Wilson Open 19 06/07/2009 Development of ETT Bundle P Gowens / Susan Wilson Open 20 06/07/2009 Action Plan against NHSQIS Learning disabilities B Mason Open Leadership and Learning Effectiveness 21 06/07/2009 Leadership for teams programme P.Gowens / Jayne Dunn Open 22 06/07/2009 Peadiatric Update PHPLS - NES P Gowens Open 23 06/07/2009 Care of the acutely ill child course-rgu Gerry Egan/ Paul Gowens Open 24 06/07/2009 Clinical Governance Higher education Programme Gerry Egan / Paul Gowens Open 25 06/07/2009 Attend Euronavigator AMPDS Conference Gerry Egan Open 26 06/07/2009 Clinical Leadership programe Cohort 5 recuitment P.Gowens / Jayne Dunn Open 27 06/07/2009 Introduction of top-team walkrounds P Gowens Open 28 06/07/2009 Reviw of top-team walkrounds actionable items G Crooks Open Resource Effectiveness 29 06/07/ Monthly review of Clinical Directorate Job Descriptions P.Gowens / G Crooks Open 30 06/07/2009 Development of Clinical tasking in EMDC Gerry Egan Open 31 06/07/2009 Development of single triage tool in colllaboration with NHS 24 Gerry Egan Open 32 06/07/ Monthly review of Divisional Clinical Leads P.Gowens Open 33 06/07/ Monthly review of Clinical Directorate Function G Crooks Open Patient Experience 34 06/07/2009 Foundation Check of PS against MaPSaF - Ambulance Framework P.Gowens Open 35 06/07/2009 Review and development of See and Treat D Wymes Open 36 06/07/2009 Development of Diabetes Pathway Gerry Egan Open Communication 37 06/07/2009 NHS 24 core clinical and Clinical Advisory groups Gerry Egan Open 38 06/07/2009 Develop communication links with Prehospital care givers Gerry Egan Open 39 06/07/2009 Development of CG Website P.Gowens Open Strategic Effectiveness 40 06/07/2009 Annual CG Report P.Gowens Open 41 06/07/2009 Board Development - Patient Safety P.Gowens / Jane Murkin Open 42 06/07/2009 Board Development - Clinical Governance P.Gowens / Kerry Walsh Open 43 06/07/2009 Development of PAG G Crooks Open 37

38 2010/2011 Work Programme Clinical Governance Work Plan - Action Tracker Author Distribution Status Paul Gowens Clinical Governance Committee Action Point No. Date Action Raised Description of Action Point Action Owner 1 06/07/2009 Review of STEPWISE approach to airway management SAD - EET - HAI RAG Status Clinical Effectivness P.Gowens J Burnham Target completion date extended and rationale provided for movement 2 04/01/2010 Trial of Vehicle issue Morphine Jill Fletcher No identified risk to action target completion date 3 06/07/2009 Review of Temperature Monitoring P Gowens Target completion date extended and rationale provided for movement 4 07/07/2009 Research- LBBB- See and Treat- Diabetes- D Fitzpaterick Task completed to be removed from listing 5 08/07/2009 Medicine Pouch roll out Gerry Egan Target completion date extended and rationale provided for movement 6 09/07/2009 Development of the 2nd v Electronic Patient Record Robin Lawrenson No identified risk to action target completion date 7 06/07/2009 W Mason/ Allan PRU Manual Shields/Gerry Egan No identified risk to action target completion date 8 12/09/2009 CGC Template for DMT P Gowens Task completed to be removed from listing Risk Management 9 06/07/2009 Action Plan against CGRM - PS standards 1,2,3 S Kilday Task completed to be removed from listing 10 06/07/2009 SEWS - Reduction of exceptions for see and treat D Milligan Task completed to be removed from listing 11 06/07/2009 Development of pro-active Trigger Tools for clinical adverse incidents D Milligan Target completion date extended and rationale provided for movement 12 06/07/2009 Devlopment of Call streaming process with NHS 24 Gerry Egan No identified risk to action target completion date 13 06/07/2009 Development of ETT Bundle P Gowens / Susan Wilson Target completion date extended and rationale provided for movement 14 06/07/2009 Action Plan against NHSQIS Learning disabilities B Mason Target completion date extended and rationale provided for movement Leadership and Learning Effectiveness 15 06/07/2009 Leadership for teams programme P.Gowens / Jayne Dunn Target completion date exceeded with further explanation required and/or to be provided at meeting 16 06/07/2009 Clinical Governance Higher Education Programme Gerry Egan Task completed to be removed from listing 17 06/07/2009 Introduction of top-team walkrounds P Gowens Target completion date exceeded with further explanation required and/or to be provided at meeting 18 06/07/2009 Reviw of top-team walkrounds actionable items G Crooks Target completion date exceeded with further explanation required and/or to be provided at meeting Resource Effectiveness 19 06/07/ Monthly review of Clinical Directorate Job Descriptions P.Gowens / G Crooks Task completed to be removed from listing 20 06/07/2009 Development of Clinical tasking in EMDC Gerry Egan Target completion date extended and rationale provided for movement 21 06/07/2009 Development of single triage tool in colllaboration with NHS 24 Gerry Egan Target completion date extended and rationale provided for movement 22 06/07/ Monthly review of Divisional Clinical Leads P.Gowens Target completion date extended and rationale provided for movement 23 06/07/ Monthly review of Clinical Directorate Function G Crooks Target completion date extended and rationale provided for movement Patient Experience 24 06/07/2009 Foundation Check of PS against MaPSaF - Ambulance Framework P.Gowens Task completed to be removed from listing 25 06/07/2009 Review and development of See and Treat D Wymes No identified risk to action target completion date 25 01/01/2010 Living and Dying Well - review against action plan R Lawrenson Task completed to be removed from listing 27 06/07/2009 Development of Diabetes Pathway Gerry Egan No identified risk to action target completion date Communication 28 06/07/2009 NHS 24 core clinical and Clinical Advisory groups Gerry Egan No identified risk to action target completion date 29 06/07/2009 Develop communication links with Prehospital care givers Gerry Egan No identified risk to action target completion date 30 06/07/2009 Development of CG Website P.Gowens Target completion date extended and rationale provided for movement Strategic Effectiveness 31 06/07/2009 Annual CG Report P.Gowens No identified risk to action target completion date 32 06/07/2009 Development of Clinical Framework C Kerr Target completion date extended and rationale provided for movement 33 12/09/2009 Development of PAG G Crooks Task completed to be removed from listing 34 12/09/2009 CHD Action Plan C Kerr Task completed to be removed from listing Task completed to be removed from listing No identified risk to action target completion date Target completion date extended and rationale provided for movement Target completion date exceeded with further explanation required and/or to be provided at meeting 38

39 Appendix C Outline Medical Directorate Structure 39