NHS Clinical Governance Annual Report 2010/2011

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1 NHS Board Meeting 22 June 2011 Paper 3 NHS Board Meeting Wednesday 22 June 2011 Subject: Purpose: Recommendation: NHS Clinical Governance Annual Report 2010/2011 To provide a report containing the key achievements, key learning and key developments for Clinical Governance for the period 2010/2011 To receive the NHS Clinical Governance Annual Report 2010/ Background Clinical Governance is a statutory obligation for NHS Ayrshire & Arran. It is 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 and patient safety will flourish. Clinical Governance establishes the need to focus on the activities involved in achieving high quality care, improving patient experience and patient safety. Current Situation This is the sixth NHS Ayrshire & Arran Clinical Governance Annual Report. The report outlines the key achievements, key learning and key developments in order the NHS Ayrshire & Arran Board can be assured that all elements of Clinical Governance activity operating effectively and complying with national guidelines Proposal The Board is asked to receive the Annual Report. 4. Engagement and consultation on development of the proposal 4.1 The Clinical Governance Committee considered and approved the Annual Report. 1 of 10

2 Resource Implications and identified source of funding Nil to note. Risk assessment and mitigation The document will be a public document in order to provide assurance to the local population. Impact assessment and consequential changes proposed to mitigate adverse impacts identified Nil to note. Conclusion The Board is asked to note the Clinical Governance Committee Annual Report 2010/11 Professor Robert Masterton, Executive Medical Director [Lynsey Pill] 6 June of 10

3 CLINICAL GOVERNANCE COMMITTEE ANNUAL REPORT of 10

4 1. Definition of Clinical Governance Clinical Governance is a statutory obligation and is a framework through which NHS Ayrshire & Arran is accountable for continuously improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. 2. Remit This is detailed in Appendix A. Members of the Clinical Governance Committee during were as follows: 3. Meetings Dr David Price, Chair Ms Kirsty Darwent, Vice Chair - Non Executive Member Ms Elaine O`Connell Non-Executive Member Professor William Stevely Board Chair, from Sept 22 Cllr David O`Neill North Ayrshire Council Ms Gillian Watson - Non Executive Member Mr Stuart Hislop - Chair Area Clinical Forum, to Sept 21 Ms Janet McKay - Chair Area Clinical Forum, from Sept 22 Ex Officio Mrs Fiona McQueen, Executive Nurse Director Dr Bob Masterton, Executive Medical Director Prof Craig White, Assistant Director Mrs Diane Murray, Assistant Director The Clinical Governance Committee met on seven occasions: 5 May June July Sept Nov January March Continuous Clinical Improvement Five key performance indicators were agreed at the end of 2009/10. These so called `big dots` are high level indicators for the Clinical Governance Committee and the Board to assess trends in patient care. These are: Adverse events Adverse drug events Healthcare acquired infection Hospital standardised mortality The patient experience 4 of 10

5 Improvement in these measures results from improvement in a multiplicity of smaller projects (small dots). Data has been presented at each meeting demonstrating improvements in data recording, analysis, data presentation, performance and the embedding of the principles of continuous improvement in patient safety and treatment within normal operating procedures. The use of the Datix computerised adverse event recording system has been of great help in this regard. The benefits of this approach were particularly highlighted by the approach taken to understand and investigate a higher than expected Hospital Standardised Mortality Rate (HSMR) at Crosshouse hospital. Today data is more dynamically available, enabling trends to be identified sooner. As with all continuous improvements, there is always more to do as targets are revised, however, the Committee acknowledges the significant progress made over the last 12 months. 5. Risk Management The use of the Datix computerised adverse event recording system was gradually rolled out throughout the organisation. The data provided is now generating useful trends and indications of key areas. The Clinical Governance Committee reviewed and updated relevant corporate risks on two occasions in line with Board policy. 6. External Reports NHS Quality Improvement Scotland (QIS) NHS Ayrshire & Arran was formally assessed by NHS QIS against the Clinical Governance and Risk Management Standards. A score of 8 out of a possible 12 was achieved against a target expectation of 9. This was a disappointing score, and was challenged, citing numerous examples of perceived misinterpretation of the evidence provided. The score was, however, upheld. A list of actions was identified by NHS Ayrshire & Arran to address the recommendations made and these are reviewed six monthly. The Clinical Governance Committee agenda and reporting style was also revised to address QIS comments. 6.1 The following reports were tabled and discussed: Mental Welfare Commission for Scotland `Too Close to See` PricewaterhouseCoopers Internal Audit Review of Attention Deficit Hyperactivity Disorder and Autistic Spectrum Disorder Services NHS QIS Indicators for Learning Disabilities PricewaterhouseCoopers Internal Audit Review of Healthcare Quality, Governance & Standards Unit Audit Scotland Report on Emergency Services Audit of Critical Care in Scotland 5 of 10

6 7. Area Clinical Governance Reports The following area annual reports were received and discussed: Primary Care Mental Health Prevention and Control of Infection (PCIT) Integrated Care and Partner Services (ICPS) Hospital Transfusion Service Drug and Therapeutics (D&T) Committee Caldicott Report Patient Focus & Public Involvement (PFPI) Annual Self Assessment Report 8. Significant Adverse Events A revised Adverse Event Policy was approved. This document supports the culture as defined in (1) above. Eighteen significant adverse events were reported to the Committee. These took the form of an independent review of the incident, identifying contributory factors and a set of conclusions and recommendations. These reports were discussed in detail by the Clinical Governance Committee and were then reviewed (or plan to be reviewed), typically after 6 months to check on progress. A review of all cases was done to identify causal trends and actions undertaken. 9. Risk Management A number of reports relating to clinical risk were tabled and discussed. Opportunity to table new risks is provided. 10. Hospital Environmental Inspections Arran and Crosshouse Hospitals were inspected following prior notification and yielded positive reports. Some improvement recommendations are being progressed. Ayr Hospital was inspected unannounced with a similar positive outcome. 11. NHS Board Reporting The Committee has provided minutes of each meeting to the NHS Board and the Clinical Governance Committee Chair has highlighted specific areas of concern or good practice to prompt Board debate. 6 of 10

7 12. Challenges for The Chair sees three key challenges: 1) Given the seemingly ever increasing scope and amount of Clinical Governance activity there is a need to further streamline the Committee reporting process without the Committee losing sight of important details. This is being addressed on an on-going basis as reporting styles are amended and refined. 2) Considerable progress has been made in continuous clinical improvement and the activities related to the safer patient initiative. There is, however, a need to ensure relevant processes are more deeply embedded in the organisation`s activities, be less dependent on the efforts of a small number of specific individuals, and that these process improvements are translated into improved clinical outcomes. These are being addressed through the `Good to great programme and `Clinical culture initiative being run via the CCIB during 2011/12. 3) There is a need for increased evidence-based standardisation of procedures to reduce variability of clinical outcomes. This includes, for instance, use of safety briefings and check lists before surgical operations. This will be done by escalating implementation through line management, then ensuring assurance through normal Board structures. 13. Chair s Conclusion The Chair concludes that the Clinical Governance Committee has fulfilled its remit and considers that there are adequate and effective Clinical Governance (including Information Governance) arrangements in place to assure the Board of its Clinical Governance duties. The Chair is grateful to all members of the Committee for their support and for the considerable work undertaken during the year. 7 of 10

8 NHS AYRSHIRE & ARRAN CLINICAL GOVERNANCE COMMITTEE Appendix A TERMS OF REFERENCE 1. Introduction 1.1 The Clinical Governance Committee is identified as a Committee of the NHS Board. The approved Terms of Reference and information on the composition and frequency of the Committee will be considered as an integral part of the Standing Orders. 1.2 The Committee will be known as the Clinical Governance Committee of the NHS Board and will be a Standing Committee of the Board. 2. Remit 2.1 To provide assurance to the NHS Board that clinical governance is being discharged in relation to the Boards statutory duty for quality of care. 3. Committee Membership 3.1 The Committee shall be established by the full NHS Board and be composed of six Non-Executive members and the Chairman. The Chair, Vice-Chair and Committee will be appointed by the Chairman of the NHS Board. 3.2 Committee membership will be reviewed at least annually. 4. Quorum 4.1 Four Non-Executive members will constitute a quorum. 5. Attendance 5.1 The Medical Director will attend in an ex-officio capacity to provide Committee with advice and guidance. 5.2 The following post holders will attend Committee as required to give account for their respective remits: Medical Director, Director of Public Health, Chief Operating Executive, Nurse Director and Chairs of Sub-committees. 5.3 The Chair of the Community Health Partnership Advisory Committee will be in attendance. 5.4 The Committee may co-opt additional advisors as required. 5.5 With the prior approval of the Chair, the Medical Director, Director of Public Health, Chief Operating Executive and Nurse Director will be able to provide deputies on an exceptional basis. 8 of 10

9 6. Frequency of Meetings 6.1 The Committee will normally meet bi-monthly but will meet at least four times per annum. 6.2 The Chair may, at any time, convene additional meetings of the Committee. 7. Authority 7.1 Committee is authorised to investigate any matters which fall within its Terms of Reference, and obtain external professional advice. 7.2 The Committee may form one or more Sub-committees to support its functions. This will include a Complaints Sub-committee and Family Health Services Reference Sub-committees. 7.3 Committee is authorised to seek and obtain any information it requires from any employee whilst taking account of policy and legal rights and responsibilities. 7.4 The Committee will have the authority to require the attendance of any employee of NHS Ayrshire and Arran, as may be required. 8. Duties 8.1 The Committee shall be responsible for the oversight of clinical governance within NHS Ayrshire and Arran. Specifically it will: 8.2 Consider and scrutinise the health system s performance in relation to its statutory duty for quality of care. 8.3 Hold the relevant officers of NHS Ayrshire and Arran to account in respect of their performance in relation to the system s duty for quality of care. 8.4 Review action taken by the Executive on recommendations made by the Committee or the NHS Ayrshire and Arran Board on clinical governance matters. 8.5 Provide assurance to the NHS Board on the operation of clinical governance within the health system in compliance with relevant national standards, highlighting problems and action being taken where appropriate. 8.6 Receive annual reports and quarterly updates from the Sub-committees established by the NHS Clinical Governance Committee in order to provide assurance and accountability. 8.7 Monitor and review risks falling within its remit. 9. Conduct of business 9.1 Meetings of Committee will be called by the Committee Chair. 9.2 The agenda and supporting papers will be sent to members at least five working days before the date of the meeting. 9 of 10

10 10. Reporting Arrangements 10.1 Minutes will be kept of the proceedings of the Committee. These will be circulated, in draft normally within five working days to the Chair of the Committee and within five working days thereafter to members, prior to consideration at a subsequent meeting of the Committee The Chair of Committee shall provide assurance on the work of the Committee and the approved minutes will be submitted to the NHS Board meeting for information The Committee will conduct an annual review of its role and function and report to the NHS Board in June each year Items requiring urgent attention by the NHS Board can be raised at any time at NHS Board Meetings, subject to the approval of the Chair. 10 of 10

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