Draft Minutes Quality Assurance Committee Meeting 16 February 2017 PUBLIC BOARD MEETING, 30 MARCH 2017

Transcription

1 Draft Minutes Quality Assurance Committee Meeting 16 February 2017 PUBLIC BOARD MEETING, 30 MARCH 2017 Present Mark Chamberlain Non-Executive Director (Chair) Allison Page Non-Executive Director (from item 2.1) In attendance: David Berridge MD Operations & Deputy Chief Medical Officer Jo Bray Trust Board Secretary Craig Brigg Director of Quality Tim Collyns Consultant Medical Microbiologist (for agenda item 2.1) Helen Gilbert Kaizen Promotion Office (KPO) Lead (for agenda item 4.6) Tracy Gill Trust Board & Membership Administrator Suzanne Hinchliffe Chief Nurse & Deputy Chief Executive (up to and including agenda item 5.5) Gillian Hodgson Head of Nursing/Nurse Consultant (for agenda item 2.1) Dr Yvette Oade Chief Medical Officer Mike Richards Clinical Director, Children s Hospital (for agenda item 2.2) Julia Roper Quality Governance Manager Anne Stanton Head of Nursing for Children s Services (for agenda item 2.2) Andy Thomas Director of Informatics Agenda Item 1 Chair of the Quality Committee 1.1 Welcome and Introduction In opening the meeting Mark Chamberlain acknowledged that Allison Page had not arrived. The meeting was not quorate until Allison Page arrived slightly late and no decisions could be made within the Committee. Then Mark Chamberlain chose to take agenda item 2 to receive the information in the presentations. Actions Discussion began at agenda item Apologies for Absence Discussion continued from agenda item 2.2 There were no apologies for absence and the meeting was quorate. 1.3 Declaration of Interests There were no declarations of interest. 1

2 Discussion continued at agenda item 3 2 Presentation & Deep Dives 2.1 Presentation on MRSA Dr Yvette Oade set the context to the long-term aim of zero cases of MRSA Bacteraemia noting the achievements made in the previous three years but also the increase that was shown in the recent data. Tim Collyns outlined the Root Cause Analysis (RCA) process; he reflected that to-date this year, there were eight bacteraemias plus one contaminant (with one awaiting attribution) attributed to LTHT, which compared with six plus one contaminant in 2015/16. Benchmarking against peers was discussed in detail and, noting the apparently poor position of LTHT, it was recognised that the slide showed absolute numbers of cases which appeared high due to the large number of patients treated by LTHT. Attributed cases were explored further and the Trust s need to improve compliance against its own defined policy was noted. Tim Collyns summarised the learning that had been gained from consulting with larger best performing trusts, which would be implemented at LTHT. He went on to outline the initiative of the Blood Vessel Health and Preservation Programme and the increasing awareness campaigns, antimicrobial stewardship and new products. Allison Page joined the meeting, 13:50. In concluding, Tim Collyns summarised the City-wide approach and noted the increase in cases across the whole health economy. He spoke of the days between accountable MRSA cases which had risen from 143 in 2013/14 to (April 31 December 2016) in 2015/16. A discussion noted lapses in care and reflected that adherence to policy could be part of this. Gillian Hodgson noted the learning and corrective action for assurance but also that repeating the same message would not work and there needed to be a shift in behaviour with more progress and assurance via a collaborative approach. Dr Yvette Oade described the process and assurance reported by the RCAs and the lessons learned. This was explained in more detail, as an example in paediatrics, by Anne Stanton. She outlined the robustness of the processes, the on-going internal review of failures in care and the need for the CSU to learn and share across the Trust for wider learning. Mark Chamberlain noted the big improvements achieved in recent years and the expressed his thanks for the hard work. In crude numbers the Trust would always stand out compared to peers, due to its large patient numbers, but the improvements made over the 2

3 past few years were worthy of reflection. Tim Collyns and Gillian Hodgson left the meeting 2.2 Independent Investigation into the Care of a Child, Recommendations and Action Plan The report provided assurance to the Committee that appropriate action had been taken in response to the recommendations from the external review; an independent investigation into the care and treatment of a child at Leeds Teaching Hospitals NHS Trust that was commissioned in conjunction with NHS England. Dr Yvette Oade set out the context of this difficult case and the sad death of a child treated by the Trust. The parents of a child had raised concerns about the standard of care their son was receiving in the Children s hospital. The purpose of the investigation was to review the care and treatment provided by the Trust and, in particular, to identify any shortfalls. Where shortfalls, or opportunities for improvement, were identified, the external investigators were asked to develop robust and realistic recommendations and action-plans to address these, to help to improve the quality of care provided to other patients. The report outlined the actions being put in place by Leeds Children s Hospital to address the recommendations which had been made. Dr Yvette Oade updated on a meeting with the family, which had taken place the day before, attended by herself, Julian Hartley, Craig Brigg and a member of staff from the Patient Experience team. The parents remained distressed and were unhappy with the content of the external report and had written to the Chief Executive to describe their concerns in December The family raised particular concerns about the omission of reference to national guidance and legislation.and considered that the report was not sufficiently balanced. Dr Yvette Oade explained that the family were given an opportunity to discuss their concerns and they were advised that the external investigation involved a comprehensive and independent review of their child s treatment and care. The investigation did not set out to determine the cause of their son s death; this would be for the Coroner to decide. The investigation did however take into account the multiple pathologies and treatments provided, including the treatment of recurrent infections, which the family were particularly concerned about. Dr Yvette Oade explained that the family were advised of the changes that had been made in the Trust, including a comprehensive programme of work to improve the culture within the organisation, including engaging both junior and senior consultants in making decisions regarding improving quality in relation to the areas highlighted by the investigation. They were advised of the specific work to support families in raising concerns about treatment 3

4 and care through initiatives such as Message to Matron and Speak to Sister and the work with Public Concern at Work to enable staff to also raise concerns. Craig Brigg spoke of the assurance in relation to the recruitment and independence of the external investigation team, which had been overseen by NHS England. Responding to a question from Mark Chamberlain, Dr Yvette Oade explained that there was agreement over the recommendations and the actions that the Trust should take. She noted that the Coroner was yet to hold an inquest into the child s death. Responding to a question from Allison Page, the independence of the external investigation team was explored further. Dr Yvette Oade explained that five experts (none of whom were from LTHT) were in the team. There had been a reference to one member of the team who had worked for LTHT a long time ago. Anne Stanton could not be precise but suggested that her understanding was that the team member had not been employed by LTHT for more than 10 years. Anne Stanton noted the range of organisations that had been involved in the child s care, explaining the limitations to the care package in the community which had inhibited discharge during periods when the child could have otherwise returned home. Referring to recommendation 3 (regarding the criteria for the selection of home care packages which should be based on knowledge and skills for the particular package of care rather than be restricted to registered nurses) within the action plan, Anne Stanton reported that this would be taken forward with the community team and Dr Yvette Oade noted that this would require a protocol, especially when such arrangements fell outside the Trust s local Commissioners. Responding to a question from Mark Chamberlain on action 10 of the plan (to prevent breakdown in clinical relationship, external opinion should be sought at an early stage if there is a conflict of opinion between a clinician and a family member). Mike Richards explained that there was already a process in place and multidisciplinary team (MDT) internal reviews and escalation processes were described in more detail, providing assurance. The explanation was supported by Suzanne Hinchliffe, and Anne Stanton summarised a range of training that was to be developed to strengthen aspects of the escalation process. There was further discussion of the action plan and it was suggested that this would be improved by adding reference to the NICE guidance, and the monitoring which would take place, in response to concerns raised by the family. The action plan would be monitored locally by the CSU at their governance meeting and through the Quality Management Group 4

5 (QMG) and reported to the Committee through the QMG meeting minutes. The Committee received the report and noted the progress against the actions in response to the recommendations. Mike Richards and Anne Stanton left the meeting Discussion continued at agenda item Minutes and Matters Arising 3.1 Minutes of the Quality Assurance Committee Meeting held on 15 December 2016 Discussion continued from agenda item 1.3 The Minutes of the meeting held 15 December 2016 were agreed to be a correct record. 3.2 Matters Arising December 2016 item 5.3 Leadership Walkround Programme Leadership Walkrounds To provide assurance on actions to follow observations from Leadership Walkrounds Craig Brigg explained the process to follow up on actions flowing from observations on Leadership Walkrounds. This had been discussed when the annual programme was presented to the Committee; The focus of the leadership walk rounds was on engaging with staff, patients and families. He spoke of the open engagement and interactions, with a summary sent to the CSU management team following a walkround to highlight areas of good practice and areas for consideration by the CSU. Craig Brigg noted that specific themes emerging through the visits would be fed back through the annual report. Suzanne Hinchliffe reflected on examples which had given rise to concerns which were then addressed by the Weekly Quality Meeting and also noted that each ward was subject to the monthly healthchecks which were reported to the Board. She reported that areas which were not achieving the quality indicators would be escalated and the process for doing this was set out. She highlighted the benefit of immediate feedback before leaving the ward following a leadership walkround and gave an example of a specific service, with issues raised at the time regarding workforce and recruitment, which was discussed in greater detail. Craig Brigg provided assurance on a workforce issue raised on a leadership walkround with Alison Page. In concluding the discussion, it was agreed that clear messaging before leaving the ward would continue to be provided to staff and to escalate issues within the CSU. Mark Chamberlain summarised and noted the processes that were in place to respond to concerns raised during leadership walkrounds. 3.3 Review of Action Tracker The Action Tracker was reviewed and progress noted. All actions 5

6 were green and were completed. Action 44 - Provide an update to a subsequent QAC meeting on the structure and impact of the service provision for patients with primary mental health needs in the Trust - the date was noted and this would be monitored by QMG. Action 51 - Future topics for deep dive, and discuss whether a report on quality process for informatics should be reviewed by QAC. It was noted this had been added to the forward plan for July meeting. 4 Topic Reports 4.1 CQC Action Plan Update The report provided an update on progress in delivering the Trust s Action Plan in response to the CQC report following the planned inspection in May The Action Plan set out actions which the Trust MUST and SHOULD take to improve quality and safety. The report included an updated version of the Plan showing progress to date against each of the individual actions. The Plan had 69 individual actions across the CQC s 24 recommendations. To date, 42 of the 69 actions had been completed, which included 35 of the 51 must do actions. Some of the actions had not yet reached the timescale for completion. Suzanne Hinchliffe summarised and provided assurance on the progress made to date. She noted that the report was to be presented to the Joint Health Overview and Scrutiny Committee the following week and to the Trust Board at their meeting on 30 March Mark Chamberlain suggested that it would be useful to have an indication on the Plan of the status of actions and if any target-dates had slipped, and an update on when these would be back on-track or completed. Craig Brigg commented that the update was provided in the action plan, including a date for completion where the time scale had passed, for assurance. However, this would be further reviewed and updated in the light of Mark Chamberlain s request. Mark Chamberlain also requested a summary of updates to the Plan reviewed the Committee meeting to that which would be presented to the Trust Board at the end of March. Craig Brigg Craig Brigg The Committee received the report and was assured by the progress in delivering the Trust s Action Plan in response to the CQC report on the planned follow-up inspection which took place in May Quality Improvement Strategy The Trust s Quality Improvement Strategy for was approved by the Trust Board in September 2014 and a detailed update provided to Board in January Updates on individual work streams had been presented to the Quality Improvement 6

7 Steering Group, Quality Assurance Committee and the Trust Board. The Report presented a draft updated Quality Improvement Strategy for including updates on the work streams prior to submission to the Trust Board for approval in March The Strategy had been refreshed to: Outline the Trust s quality improvement ambitions for the organisation in the future; Describe the organisational approach to improvement, bringing together the existing quality improvement approach with the Leeds Improvement Method; Showcase the quality improvement successes to date; and, Explain to staff how they could get involved. Dr Yvette Oade set the context to the refresh of the Quality Improvement Strategy drawing attention to the ambition, methodology, successes and future projects. Mark Chamberlain spoke positively about the Quality Improvement Strategy and it was agreed that Ali Cracknell, Consultant Geriatrician and Trust Lead for Patient Safety, Lorna Johnson, Quality Improvement Nursing Lead and Julia Roper, Quality Improvement Management Lead, would be invited to present the Strategy to the Trust Board in March Jo Bray The Committee noted the update on the Trust s Quality Improvement Programmes; and, supported the Quality Improvement Strategy for for presentation to the Board. 4.3 Annual Quality Assurance Committee Report The previous annual report of the Quality Assurance Committee (QAC) had been reviewed by the QAC in February 2016 and by the Audit Committee (AC) on 6 April The annual report of the QAC for January to December 2016 was presented for review prior to being presented to the 8 March 2017 AC meeting. The report provided an update on the work of the QAC and assurance to the Trust Board, via the AC, that the Committee had carried out its obligations in accordance with its Terms of Reference. The Committee received the annual report and supported its presentation to the Audit Committee on 8 March Review of Quality Assurance Committee Terms of Reference & Work Plan 2017/18 The report included the proposed revisions, shown in tracked changes, to the Quality Assurance Committee s Terms of Reference (ToR), reflecting changes to the membership, Committee Chair and regular attendance. The ToR were presented along with the draft work plan for 2017/18. The Committee approved the changes to its Terms of Reference and the draft work plan for 2017/18, which would be submitted to the Trust Board for approval. 4.5 Report on Nasogastric Tube Misplacement Jo Bray 7

8 Misplacement of nasogastric (NG) tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts had been issued by the NPSA and NHS England between 2011 and Feeding via a misplaced NG tube was defined as a Never Event. LTHT had reported four such Never Events in June 2011, October 2011, September 2012 and June Since then a significant programme of work had been put into place to reduce the risk and the work that had been done in LTHT has been recognised nationally as good practice. The latest Patient Safety Alert (NHS/PSA/RE2016/006) had asked every organisation using NG tubes to: Identify a named executive director to take responsibility for the delivery of the actions required in the alert; and, Take a co-ordinated assessment of the safety systems related to NG tubes and to develop and implement and action plan for any deficiencies. Craig Brigg reported that this requirement had been reviewed in detail by the Quality Management Group in February 2016 and assurance had been provided; he noted that the Trust Board were required to receive assurance and this would be provided through the minutes of the Quality Assurance Committee, a formal committee of the Board, and also the Chair s report. He reflected that despite all the safety mechanisms in place, occurrences of this Never Event was still being reported nationally, which had resulted in the actions required in the latest Patient Safety Alert. The Committee noted the assurance provided in the report which would be drawn to the attention of the Trust Board. Julia Roper Discussion continued at agenda item Leeds Improvement Method Discussion continued from agenda item 5.1 Helen Gilbert joined the meeting Helen Gilbert began the presentation by asking what she termed the BIG Question originally put to her by Mark Chamberlain, which was: How can we be assured that the benefits from the Leeds Improvement Method are being realised in a sustainable way? and went on to explore this in the context of the objectives of the Quality Assurance Committee. The presentation included updates on two Rapid Process Improvement Workshops (RPIW). Mark Chamberlain enquired further about the support and engagement with the Kaizen Promotion Office (KPO) Team, which was explained in more detail. Helen Gilbert outlined the principles of reviewing progress at 30, 60 and 90 days and the aim of spreading 8

9 out to the wider Trust. The presentation included examples of progress measurement and Mark Chamberlain enquired about the metrics and indications of sustainability which were explored further. Helen Gilbert reflected on the change in behaviours which would indicate sustainability and which may not be articulated well at the high level of the value stream. Dr Yvette Oade summarised the five-year duration of the project and questioned the wider sustainability and noted that the challenge to the Trust would be its choice to continue to use the methodology beyond that time-scale. Helen Gilbert reflected on the challenge posed by the question and provided an insight into her thoughts around it. Dr Yvette Oade referred to the Staff Engagement Event, which was scheduled to take place on 28 March 2017 and which would involve around 600 members of staff. It was suggested that a future evaluation of sustainability could be presented by lead teams. Helen Gilbert Mark Chamberlain thanked Helen Gilbert for the presentation. Helen Gilbert left the meeting Discussion continued at agenda item Assurance Reports 5.1 Minutes from Quality Management Group Meetings Approved Minutes of the Meeting held 1 December 2016 Discussion continued from agenda item 4.5 David Berridge drew attention to item 2.2, SBAR on Reporting of Cardiac Arrests, and noted the good work being undertaken by Ali Cracknell and the team. Responding to a question from Mark Chamberlain on item 6.3, Safety & Outcomes Sub-Group October 2016 Minutes, David Berridge provided context to the potential use of GS1 barcodes, and inventory of equipment was explained in more detail. These approved minutes of the Quality Management Group meeting held 1 December 2016 were received and noted. Approved Minutes of the Meeting held 12 January 2017 Responding to a question from Mark Chamberlain about the proposed start date to re-establish a Clinical Ethics Committee, item 2.1, Dr Yvette Oade reported that the proposal anticipated this could begin in March She drew attention to the link with (QAC) agenda item 2.2 and one of the recommendations in the investigation report. 9

10 These approved minutes of the Quality Management Group meeting held 12 January 2017 were received and noted. Discussion continued at agenda item Six monthly Report on Incidents, Complaints and Claims Discussion continued from agenda item 4.6 The report provided a detailed review of the Trust s activity in relation to incidents; inquests; claims; Patient Advice and Liaison Service (PALS) usage; and, Complaints for the first two quarters of 2016/17. Where possible, comparisons had been made with data available nationally to assess the Trust s overall performance. Nationally 75.5% of patient incidents reported resulted in no injury; within the Trust this was 85.9%; There was one Regulation 28 report (where the Coroner considers a death may have been avoidable and where future deaths can be prevented if specific actions were taken); Personal Injury claims increased by 65% (compared to the same period in 2015/16) and represented a reversal in the trend seen in the previous two years; New potential clinical negligence claims received increased by 1.3%; The Trust saw a 12% increase in PALS and a 29% decrease in complaints; and, 40% of complaints were closed in the first two quarters of 2016/17 and met the Trust s standard of 40 working days from receipt to response. Craig Brigg updated on the detailed review which had taken place by the Quality Management Group (QMG), including the appendix that set out the incidents, claims, complaints and coroner s inquest profile by CSU and the key themes emerging from this, with examples of key learning points. He noted that QMG had agreed this would be an annual report and would not include complaints/pals in future as this was already reported to the Trust Board. He reflected that the QMG had discussed the greater focus on assurance and recognition of key trends that was required rather than the current format which was considered to be too detailed. Mark Chamberlain reflected on his recent visit to the Complaints Team and, making reference to the process for learning from for Serious Incidents, enquired if the process for Complaints was similar. Suzanne Hinchliffe explained the detailed investigation of complaints and concerns and the review by the Weekly Quality Meeting, chaired by either herself or Dr Yvette Oade. She explained that complaints could, albeit rarely, be the result of a Serious Incident. She went on to reflect that all complaints response letters were reviewed by either herself or Dr Yvette Oade. Dr Yvette Oade confirmed that where a response was sent from the Chief Executive, these were subject to the same review. 10

11 Craig Brigg noted that CSUs reviewed complaints as part of their monthly governance meetings. He went on to highlight the need to provide information at the right level of detail to ensure there was good cross-learning across the organisation. Sections 7.1 and 7.7 were drawn to the Committee s attention and Craig Brigg reflected on the process for providing independent support to staff involved in incidents. He made reference to LTHT as leading nationally in providing training and development of a qualification in Serious Incident Investigation. The Committee received and noted the report, agreeing the changes to future reports. 5.3 Quality Metrics Report Dr Yvette Oade requested that this item should be discussed earlier in the agenda for future Quality Assurance Committee meetings. This was agreed by the committee. Julia Roper Referring to page 5, Mortality Indicator Reporting, Mark Chamberlain noted that the chart (top right) for Number of In-Hospital Deaths, showed an increase overall. Responding, David Berridge provided assurance reflecting that the Trust was ranked fifth highest for the volume of patients treated and that this was reflected in the expected number of patient deaths. He drew attention to the funnel plot below (bottom right) and noted that the results for LTHT were statistically where they would be expected to be and within safe confidence limits. He updated the meeting on the Dr Foster pilot, which was on-going, which utilised live information and significantly reduced the time lag (currently three months) to reporting. The discussion noted the cross-reference to a presentation to the Board at their March meeting on the Dr Foster overview. Dr Yvette Oade reported that she reviewed the number of deaths within the Trust on a weekly basis. She also reflected on the number of patients that needed advanced care planning as many patients were admitted to hospital towards the end of their life, which needed more work with community colleagues; this would continue to be addressed through the End of Life Group. The discussion noted that the number of deaths chart (top right) should be removed from the chart, although overall patient mortality would remain an important metric for the committee. Andy Thomas Andy Thomas noted the inclusion of Sepsis and Acute Kidney Injury at pages 7 and 8 respectively. He drew attention to the lack of data in September 2016 (page 8) due to the pathology outage. Turning to page 16 of the report, Incidence of CDI, and responding to a question from Mark Chamberlain, Dr Yvette Oade noted that the Trust was within the threshold that had been set. The discussion noted possible over-reporting by LTHT when compared to peers due to the stringency of processes used within the Trust. 11

12 Dr Yvette Oade drew attention to the 10 and 8 cases in the first two quarters respectively which had been accepted as showing no lapse in care and reflected on the 11 cases for Quarter 3 which had been submitted for review. Referring to page 17, Harm Free Care Pressure Ulcers, Mark Chamberlain noted the number was slightly outside the confidence levels on the chart. Suzanne Hinchliffe explained that more patients were admitted with existing pressure ulcers and outlined the improvement work being launched for the early detection and management of pressure ulcers. She reflected on the understanding of clusters of patients with pressure ulcers and where these had been admitted from. The Committee thought information about unavoidable pressure ulcers would be useful and this would be added to the report. She noted the metrics for each ward to monitor pressure ulcers. Andy Thomas The Committee received and noted the report. 5.4 Six-monthly Safeguarding Report (Annual Report 2015/16 in Blue Box) The report provided information on the activities of the Trust Safeguarding Team and assurance that the Trust was meeting its statutory obligations and fulfilling its responsibilities for safeguarding and areas of good practice and progress. Following the CQC inspection in May 2016 a recommendation was made that LTHT should ensure that all staff were trained to the appropriate level of safeguarding competency, according to their role and responsibilities. The new safeguarding mandatory training programme would offer a variety of learning mechanisms. It would commence in Quarter /18 following communication and update across the Trust and CSUs. During the current year safeguarding activity over Quarters 1, 2 and going into 3, had seen an increase in the number of referrals into both the children and adult teams. The safeguarding teams were also reporting an increase in the complexity of cases referred. Section 4 of the report summarised Serious Case Reviews (SCRs), Safeguarding Adult Reviews (SARs) and Domestic Homicide Reviews (DHRs): There had been one SCR commissioned by Leeds Safeguarding Children Board in Quarter 2; There had been three SARs commissioned by Leeds Safeguarding Adult Board; LTHT had identified the report authors and would also provide representation at the SAR panels; There had been no new notifications for DHR investigations brought to the attention of the Trust in Quarters 1 and 2; The Trust had attended the initial panel meeting for the DHR19 which was held in Quarter 2; and, Following the death of a 17-year-old in Quarter 2 a decision by 12

13 Leeds Safeguarding Children Board and Safer Leeds was that this review would follow a joint SCR and DHR process. This would be the first joint SCR and DHR review in Leeds. LTHT had identified report authors and had attended the initial panel meeting. Suzanne Hinchliffe described the governance arrangements for reporting on safeguarding and explained that the Safeguarding Annual Report (included in the Blue Box) had not been presented to the Committee upon completion in September This was therefore presented for assurance and completeness. The Committee received and noted the report. 5.5 Serious Incident Report (including Never Events) There had been 10 Serious Incidents reported to Commissioners between December 2016 and January 2017; new activity launched by Risk Management included the Leeds Incident Support Team (LIST) and the Level 5 training in Investigating Serious Incidents in Health Care. The report summarised the new incidents reported to Commissioners at NHS Leeds West CCG during the period with information about the initial actions taken to mitigate the associated risks; closed investigations for the period; and, focussed on the actions taken and lessons learned from Serious Incidents. A total of 15 potential Serious Incidents were reported in the period December 2016 and January 2017 of which 10 were declared to the Commissioners via the Strategic Executive Information System (STEIS) as Serous Incidents. Section 5 of the report, Never Events, reported that there had been four Never Events declared to date in 2016/17 which were: 2 X wrong site surgery; 1 X wrong side block; and, 1 X wrong tooth extraction. There were no Never Events reported for this period (December and January). A workshop had been held on 17 January 2017 (section 6 of the report) introducing staff to the principles of human factors training. Further workshops were to be provided. In September 2016, Risk Management had launched the Leeds Incident Support Team (LIST). LIST buddies had undergone training provided by Risk Management and to date the LIST consisted of 30 buddies. Section 8 of the report provided details of the qualification developed which was a Level 5 Investigating Serious Incidents in Healthcare. The qualification would be available to other trusts to deliver to provide consistency across the system when conducting Serious Incident Investigations. 13

14 The Committee received the Serious Incident Report for the period December 2016 and January 2017: noted the new Serious Incidents that had been reported, including initial actions taken to mitigate risks; noted the closed incident investigations and the learning identified and actions to be implemented from these; and, noted the developments regarding human factors training, support to staff involved in an investigation (LIST) and the accreditations of incident investigation training. 5.6 Quality Account Preparation 2016/17 For Noting The report provided a summary of the process for producing and reviewing the Trust s 2016/17 Quality Account, which the Trust was required to publish at the end of June 2017 alongside the Annual Report and Financial Accounts. The Committee received and noted the report and supported the timetable for production and review of the Trust s Quality Account for 2016/17. 6 Any Other Business 6.1 Topics for Future Deep Dives Sepsis and Acute Kidney Injury to be presented at the 25 April 2017 meeting; and, National reporting system on quality of treatment for Cancer patients to be presented at the 12 July 2017 meeting. Any issues to be escalated to the Board Dr Yvette Oade reflected on the scrutiny and assurance by the QAC relating to agenda item 2.2 regarding the independent investigation into the care of a child which would be brought to the Board s attention. There were no issues to be escalated to the Board but the assurance provided at agenda item 4.5 in respect of nasogastric tube misplacement would be drawn to the Board s attention. Availability of ITU beds assurance Mark Chamberlain Suzanne Hinchliffe responded to a question by Mark Chamberlain, reflecting on the workforce and capacity issues of the previous year, and in particular the availability of sufficient intensive care beds. She noted that the bed base in critical care had been increased as a result of recruitment. There was a wider discussion on suitability of patients for high-dependency and critical care beds and pressures noted within the Trust on cardiac and major trauma activity and the response being constrained by the capacity available. For Emergency and Urgent care there was capacity but this did not always permit the targeted elective activity. Processes and escalation of operational issues were discussed and it was noted that the wider estates plan for the LGI would ultimately provide more capacity. It was noted that current actions within the Trust were in place to ensure safe care in relation to this issue. Children s Cystic Fibrosis Suzanne Hinchliffe Referring to part of the discussion relating to an issue raised by Allison Page during a walkaround, in agenda item 3.2.1, Suzanne Mark Chamberlain Mark Chamberlain 14

15 Hinchliffe confirmed that the pathway was particularly complex. Operational staffing changes had been reviewed with a nursing establishment SBAR submitted to Corporate Nursing. In the shortterm, the Heads of Nursing discussed patient acuity levels at the daily bed meeting to ensure staffing was appropriate to patient needs. 7 Date of Next Meeting 25 April 2017, Agenda and covering to confirm start time. Venue: Seminar Room 2, Gledhow Wing, SJUH The meeting closed at 16:25. 15