Attendees. In attendance. Volunteers Strategy only: Minutes. 1 Chair s introductory remarks

Transcription

1 Approved minutes The NHS National Waiting Times Centre Board Board Meeting (Public) Date: Thursday 12 December 2013 Venue: Level 5 Boardroom, Golden Jubilee National Hospital Attendees NWTC/2014/01/01 Jeane Freeman (JF) Jack Rae (JackR) Mark MacGregor (MM) Stewart Mackinnon (SM) Maire Whitehead (MW) Kay Harriman (KH) Philip Cox (PC) Jane Christie (JaneC) Jill Young (JY) June Rogers (JR) Mike Higgins (MH) Shona Chaib (SC) Julie Carter (JC) Lindsey Ferries (LF) Chairman (Chair) Non Executive Board Member Non Executive Board Member Non Executive Board Member Non Executive Board Member Non Executive Board Member Non Executive Board Member Employee Director Chief Executive Director of Operations Medical Director Nurse Director Director of Finance Director of Human Resources In attendance Sandie Scott (SS) Volunteers Strategy only: Paul Graham (PG) Doreen Lovett Sandra Pairman Head of Corporate Affairs Spiritual Care and Diversity Lead Volunteer Volunteer Minutes Christine McGuinness Corporate Affairs Officer 1 Chair s introductory remarks 1.1 JF welcomed everyone to the meeting, in particular Paul Graham, the Board s Spiritual Care and Diversity Lead, and two of our volunteers, Doreen Lovett and Sandra Pairman. 1.2 JY updated the Board on the successful launch of our innovation cafe on Wednesday 11 December 2013, by Dr Heather Reid. The cafe, when opened next year, will provide staff with a drop in centre to explore innovation ideas, access support or develop projects, whether that is in ground-breaking medical research, developing new ways to treat patients faster, or even a new way of fulfilling their role better. 1.3 JF advised that the Scottish Government Health Directorate has issued a new Chief Executive Letter (CEL) relating to use of the Beardmore Hotel and Conference Centre. 1

2 The CEL states that the Beardmore should be the first port of call for NHS organisations and advises use by other government and public sector organisations. 2 Apologies 2.1 There was full attendance at the meeting. 3 Minutes 3.1 Minutes of the meeting held on 31 October 2013 were approved as accurate subject to the following amendments: P5, amend to read LF stated that the exact number is not known, but it is known that a large number of staff choose not to be a member of any union. P8, amend waiting times audit policy to the Patient Rights Act P8, amend transplant list to rota. P10, amend to read JY responded that forecasts are received daily in the height of winter. SC added there is also an excellent report which can be referred to on weather predictions. P11, amend to read JF commented that, during the annual review meeting, patients and volunteers raised concerns about optimising patient flow through the Booking Office. She stated that, although it is not a major issue, are we confident that changes have been put in place. JY replied that more needs to be done in the longer term and she will have a discussion with JR regarding communication between the Booking Office and patients. P13, amend to read MM stated he has worked with an electronic record for 20 years and it is still not paper-light and it might have increased quality but not necessarily efficiency. WE recognised that point, however with our scanning module he sees a solution. P13, amend staff benefits to the negative impact on staff work-life balance. 4 Matters and actions arising 4.1 Action list All actions were completed with the exception of the following. Action no: /05 Action: JF suggested holding a future Board meeting followed by a series of presentations into research from all consultants. Action by: MH to organise in this financial year Status: Ongoing Update: Will be arranged to link in with refreshed Research Strategy Action no: /06 Action: JF will send a template to SC and members will provide their own input at the risk workshop. Action by: JF Action status: Ongoing 2

3 Action no: /06 Action: Circulate final version of Management Statement Action by: JC Action status: Ongoing Update: Awaiting sign off by Scottish Government Action no: /05 Action: Establish how Non Executive Members can access the Values Dashboard Action by: SC/LF Action status: Ongoing Update: Secure URL and login should be available early in Action no: /06 Action: Governance Committees to add Values Dashboard work to agendas Action by: Executive and Non Executive Leads Action status: Ongoing Update: Actioned by CGC/PCC; JC/SM to discuss if appropriate for AC. Action no: /07 Action: Review of HeartMath on Board agenda in 12 months time Action by: SC Action status: Ongoing Update: Update to the Board by 13 March 2014 meeting 4.2 Matters arising There were no matters arising to discuss. 4.3 Conflicts of Interest There were no declarations of interest. PG entered the meeting with volunteers Doreen Lovett and Sandra Pairman. 5 Presentation 5.1 Volunteers Strategy The Board was given an update on progress in developing the new Volunteers Strategy by Paul Graham, Spiritual Care and Diversity Lead. As well as hearing about the types and numbers of volunteers, Board members got to hear first hand from two volunteers who attended the meeting There was a lengthy discussion around the recruitment process, as well as plans for recruiting more volunteers and developing new roles to further enhance the patient experience. There was also discussion about implementing more structure to the volunteering programme The Board agreed that more should be done to support the volunteering programme, and agreed a range of actions to move this forward. 3

4 Action no: /01 Action: Discuss issues around Disclosure/PVG checks for volunteers to see if further intervention is needed to speed up the process Action by: LF/PG Action no: /02 Action: Implement more structure to volunteer programme Action by: SC/PG Action no: /03 Action: Look at potential quality bid to support volunteer programme Action by: JC/PG Action no: /04 Action: Consider alternatives to certificates of achievement at annual volunteer event Action by: PG JF thanked Paul, Doreen and Sandra for giving up their time to attend. PG, Doreen and Sandra left the meeting. 6 Person Centred 6.1 Person Centred Committee minutes The Board noted the approved minutes from the meeting held on 27 August Person Centred Committee update JackR updated the Board on discussions from the meeting held on 26 November Person Centred The Committee received updates from the Partnership Forum. Concerns about KSF activity were raised as approximately 50% of Agenda for Change staff do not have a current Personal Development Review recorded on the system. It was noted that the 2013 Staff Survey results are awaiting Scottish Government release. The Involving People Report (including feedback, comments, concerns and complaints) was discussed. It was recognised that the same report was presented at the Clinical Governance Committee and that in future, the content should be focused towards person centered activities. It was also agreed that this report should be once every six months, alternating between PCC and CGC. The Values Report was discussed and activity to date noted. 4

5 Safe The Occupational Health and Safety Report was discussed. It was agreed that the quarterly corporate Learning and Development and Clinical Education Report should be discussed on a six monthly basis in future. Discussion took place regarding sickness absence and potential hotspots. A brief report was given by the Chair in relation to the low levels of sickness absence in the Beardmore Hotel. Effective The Committee reviewed and made a couple of minor changes to the terms of reference. The Committee noted the content of the Remuneration Committee held on 31 October The Internal Audit Review of corporate governance arrangements was tabled whilst awaiting Audit Committee approval. The Chief Executive presented the quality dashboard for Committee members LF advised that a new website has been launched to support the Knowledge and Skills Framework, and JackR noted that a national review is being led by Malcolm Wright, Chief Executive, NHS Education Scotland JackR advised that the results of the NHSScotland Staff Survey 2013 will be received today ahead of their publication tomorrow (13 December 2013) The Board noted the update. 6.3 Workforce Monitoring Report LF presented for approval the Workforce Monitoring Report for the period 1 April to 30 September 2013, highlighting that work has continued to enhance the equality monitoring data included and to review and analyse this in order that we can record and investigate trends and also produce action plans to act on the outcomes of these investigations The Board workforce is increasing year on year, which is very positive. The workforce itself has increased by 44 whole time equivalent (WTE) to 1,492 substantive staff over the past six months. The increase is a result of an expansion programme across a number of different areas within the Board, including Orthopaedics and Ophthalmology JaneC asked if there is any best practice around recruitment of staff, given the 15 weeks it is currently taking to complete. LF responded that three months is a minimum period when taking into account references, Disclosure checks and notice periods SM agreed that 15 weeks from appointment to start date is reasonable with a threemonth notice period but KH highlighted that, although this is an acceptable time period for senior roles, junior roles could be appointed in a shorter time period. LF agreed to look into it. 5

6 Action no: /05 Action: Review recruitment timescales particularly for junior roles Action by: LG PC asked if the corporate staff group could be split into more specific details. LF agreed to review the category headings. Action no: /06 Action: Review and agree category headings within report (corporate/workforce) Action by: LF/JY Following discussion about sickness absence figures, LF agreed to discuss the reconciliation in more detail with JackR. Action no: /07 Action: Discuss reconciliation of sickness absence figures Action by: LF/EB/JackR Following discussion about the usefulness of some data, such as the numbers of staff who are married or in civil partnerships, it was agreed that the next report should be split into two sections with the rationale behind each: one highlighting the data we are legally required to monitor and the other with the information we wish to record as a Board to inform our own workforce activity Action no: /08 Action: Split next workforce monitoring report into two clear parts Action by: LF/EB The Board approved the Workforce Monitoring Report, and its publication on the website, subject to the amendments discussed. Action no: /09 Action: Publish Workforce Monitoring Report Action by: Comms 6.4 Consultant Appointments The Board ratified the appointments of four new Consultants following recent recruitment panels. Two part-time Consultant Ophthalmologist posts were offered to Dr Patrick Kearns and Mr Arvind Singh. Two Consultant in Cardiothoracic Anaesthesia and Critical Care posts were offered, one substantive to Dr Antony Vassalos and one locum to Dr Patrick Breen. 6

7 7 Safe 7.1 HAIRT SC updated the Board on the Healthcare Associated Infection (HAI) based on October 2013 data. Bacteraemias one case to report. Clostridium Difficile infection one case to report, first in 2013/14. Hand hygiene Combined Compliance and Technique are sustained 99%, with the next audit period commencing in December. Cleaning and healthcare environment - Estates and Housekeeping compliance data average scores are 98.7% and 97% respectively. Surgical site infection (SSI) currently within control limits The Board noted the HAIRT report and approved its publication on the website. Action no: /10 Action: Publish HAIRT Report Action by: Comms 7.2 Clinical Governance minutes The Board noted the approved minutes from the Clinical Governance Committee meeting held on 20 August Clinical Governance update: 26 Nov MM updated the Board on discussions from the meeting held on 26 November Person Centred The committee heard a patient story about a transplant patient in ICU who had been married in the unit over the September weekend. In order to make the event happen, all five Board values were enacted, and all staff involved were committed to make the event very special. This included the Registrar officiating at the event at short notice. Although originally thought to have a very poor prognosis, the patient is now doing well. Key elements of the Francis Report were discussed and members reassured that this report is being reviewed and necessary improvement actions implemented, led by the Nurse and Medical Directors. Safe The Surgical Services risk report was presented by the Head of Operations and there were detailed discussions around several Incident Reviews. The statistical process charts for mortality and other key outcomes were well received, as this provides more informative detail. The Regional National Medicine risk report was also discussed and ongoing improvements in information were noted. 7

8 There was detailed discussion and review of the National Approach to Learning from Adverse Event Framework and the Board s Incident Management action plan. Effective The schedule of Clinical Governance Department reviews of activity was approved and it was noted much of this work is likely to take place in the first two quarters of 2014 when the department will have more consistent staffing capacity. There was further discussion of how effectiveness might be measured across each clinical area, and it was requested that thought was given to how measures might be developed, recognising the difficulty of the task MM also provided an update on reporting outcomes and clinical effectiveness within cardiothoracic programmes in NHS England. It was agreed that he should keep SC and MH informed of any developments in this area. Action no: /11 Action: Keep SC/MH informed of developments in reporting clinical outcomes Action by: MM Following discussion about complaints, and suggestions from the SPSO about how Boards are kept in the loop about details, it was agreed that the Governance Committees should determine the most appropriate ways of sharing complaints. Action no: /12 Action: Discuss best way to review complaints at Board level and governance committees?? Action by: Governance Committees The Board noted the update. 8 Effective 8.1 Performance JY presented an exception report detailing matters of interest discussed at the November Performance and Planning Committee and highlighted the key areas of focus. Person Centred Complaints there is a national target of 20 days to respond to complaints and during September of the two received one did not meet that timescale. Grievances During the second quarter there was a sharp increase in the number of grievances received by the Board all relating to one issue regarding the payment of staff while on annual/sick leave. However, because the matter concerned is a national issue and resolution has been secured and is being actioned by our Board and the wages department in Glasgow, the union concerned has agreed to suspend their pursuit of the individual cases at GJNH. 8

9 Safe. The Board noted that we continue to achieve the national HEAT targets for MRSA/MSSA bacterium and clostridium difficile infection rates. Effective The Board received a snapshot of the total number of patients waiting for cardiac surgery, thoracic surgery and cardiology with a breakdown of the number of available and unavailable patients. The Board were advised that waiting list management continues to be a key priority for both the Surgical Specialties and Regional National Medicine divisions particularly in the run-up to the festive period. Bed occupancy within acute wards remains broadly in line with the previous month, but it is anticipated that the relocation of ward beds and opening of the Surgical Day Unit will have a positive effect from February 2014 onwards KH asked about the potential impact of grievances over pay whilst on annual leave. JC advised this was likely to be in the region of 500k backdated to 2009, with recurring costs of around 10.8K JF asked for an update on consultant job planning. MH assured her that this was almost complete and JC added that once this part is completed, she will start discussions around funding JF asked for an update on occupancy within the Beardmore Centre for Health Science. JY, MH and JC assured her that this will be reviewed and addressed as part of the marketing strategy JackR asked if there is a risk around the capacity model for interventional cardiology. JY responded that there is a regional issue but assured him that we will provide funding until the issue is resolved to ensure that there are no detrimental affects to patients JackR asked about issues surrounding pre-operative assessment for elective thoracic (lung) patients. MH assured him that this will be addressed as part of the redesign of services The Board noted the update. 8.2 Business Update JR updated the Board on hospital activity for October Inpatients/day case procedures measured against a projection of 8,733 (which excludes cardiothoracic/cardiology activity) was ahead of plan by 51 procedures (6.6%) for the month when adjusted to reflect orthopaedic complexity. Diagnostic imaging carried out 1,630 examinations in the month, which was ahead of plan by 395 (32%). The mobile MRI scanner carried out 227 examinations in the first four weeks in situ. When measured against an activity projection of 23,528, the combined inpatient/day case and imaging activity for the month was 415 (3%) ahead of plan. 9

10 However, when adjusted to reflect complexity the combined inpatient/day case and imaging activity for the month was 695 (5.1%) ahead of plan JR also advised that there will be more flexibility in the next few months following the creation of a new Surgical Day Unit, co-location of cardiothoracic (heart and lung) services on one floor, and opening of a new cardiology ward JF asked for an update on the latest Orthopaedic outpatient expansion plans. JC advised that the capital work has begun MW asked for more information about unavailable patients. JR advised that this is where patients advise they are unavailable for personal reasons, or we are advised that they are unavailable for medical reasons. JF added that details are included in the performance report MM asked about the variance in electrophysiology and whether this is a supply or demand issue. JY advised it is both due to there being a single operator and MH reassured him that we are looking at recruiting, although there are few specialists in this field. JY also reassured MM that the issue is raised at every meeting of the Regional Planning Group and that additional sessions are underway MM asked about the variance in planned diagnostic versus interventional cardiology activity and whether this means we should change the plan. JC advised that the target numbers are what Boards provide funding for but are reviewed regularly The Board noted the update. 8.3 Finance Update JC updated the Board on the current financial position. Year-to-date results show a total surplus of 1.687m and it is anticipated that the Board is likely to deliver the financial targets by year-end. Bids for non-recurring and recurring investment have been assessed and feedback was provided to managers to allow sufficient time for procurement prior to year end. Quality investment bids will be summarised and taken to the strategic projects group for consideration with particular emphasis on understanding the improvements in quality. The boiler decentralisation project has encountered delays in developing the technical solution but tthe project group continue to meet to discuss the detail of this and updates will be provided once the final design has been agreed. The joint contract that the Board has for internal audit services is due for renewal at the end of the financial year (31 March 2014). Following the regional work with regard to the provision of internal audit services, three Boards have agreed to undertake a joint tender for internal audit services from April 2014, namely NHS Greater Glasgow & Clyde, NHS Ayrshire & Arran and our Board. Work is commencing to identify efficiency savings for the next financial year during November. Additional sessions will be provided to Divisional teams and additional input will be provided by the Finance team to assist with the recognition of viable schemes to be delivered in the next financial year. 10

11 At month seven, recurring efficiency savings to date are 1.119m against a plan of 850k. We also have non-recurring savings to date of 663k; these are also detailed in the appendix to this paper The Board noted the update. 8.4 Audit Committee update: 10 Dec SM updated the Board on discussions at the meeting held on 10 December Person Centred The committee received an update on the most recent Audit Scotland reports on NHS Financial Performance and Managing Early Departures from the Scottish Public Sector. Safe The follow-up report on waiting times was presented, and it was noted all actions are in progress or completed with only one point requiring further management action due to system issues. The auditors provided assurance that further controls have been put in place until a system solution can be found. Effective The Internal Audit review on corporate governance arrangements was presented to the Committee, highlighting seven advisory recommendations. The Committee noted the review of corporate risk management and requested this includes the recommendation to strengthen the role of the Audit Committee. The committee requested an input to this review with feedback provided to the next meeting. It was also agreed the internal audit review be presented to the Board for approval and then passed back to the Governance Committees to implement their specific actions An update on internal audit included progress on audits of information governance and the review of controls for the Beardmore Centre for Health Science. The External Audit plan was approved. The Committee noted a payment due to HMRC for acquisition tax on goods received from European suppliers (mainly cath lab consumables). The SMT risk workshop had taken place with the Board session organised for 12 December. A fraud update included the proactive plan for 2013/14. The committee also discussed the healthcare tourism issue and it was noted the Board is now a member of this national group. The policy on this issue will be presented to the next Committee meeting. An update on the internal audit tender was discussed and it was noted that the interviews are likely to take place in early March with the new contract due to commence in 2014/ Following discussion, it was agreed that an update on Audit/Risk should be provided at the March Board Meeting. 11

12 Action no: /13 Action: Update on Audit/Risk work Action by: JC/SM by 13 March 2014 Board Meeting 8.5 Counter Fraud proactive plan JC updated the Board on the NWTC proactive plan for counter fraud. This has been prepared, incorporating comments from Human Resources, Learning and Development, Communications, the Employee Director, Counter Fraud Champion and staff from NHS Counter Fraud Services (CFS). Actions from the CFS proactive plan have been used to inform the Board s plan for the year in conjunction with recommendations from CEL (2013) The Board noted the Proactive Plan. 8.6 Counter Fraud checklist JC also updated the Board on the NWTC Counter Fraud checklist. The checklist now has to be completed annually following guidance included in CEL (2013) 11. The checklist identifies the Board response to each of the questions contained in the list. As a result, it is recommended that additional work is undertaken in: o aligning the Board s Counter Fraud Strategy with the Government Strategy; o fraud proofing/impact assessing relevant policies/procedures; o implementation of the e-learning programme; o publicising fraud cases; and o undertaking the fraud risk assessment. It can be noted from the checklist and action plan that there are plans in place to address all these areas The Board noted the Counter Fraud checklist. 8.7 Waiting Times Report JC updated the Board on the audit report into NWTC waiting times, providing assurance that all recommendations are being progressed The Board approved submission of the updated report to the Scottish Government. Action no: /14 Action: Sign audit report and submit to SGHD Action by: JC 12

13 9 AOCB 9.1 White paper on Independence JF advised the Board that the white paper on independence has been published ahead of the referendum in 2014 and reminded members about the specific Codes of Conduct for them and for staff. JF requested that staff be informed of this; SS advised that something is already included in the December issue of the staff magazine. 9.2 Thanks Speaking on behalf of the Board, JF thanked all staff for their contributions in 2013, commenting that 2014 looks like being even more exciting. 10 Date and time of next meeting 10.1 The next meeting will take place on Thursday 30 January 2014 at 9.30am. 13