NHS Board Meeting 8 October 2008 Paper 6 NHS BOARD MEETING 8 October 2008 Subject: Purpose: Minutes of Clinical Governance Committee of the Board To report to the Board Recommendation: To receive the Clinical Governance Committee Minutes 1. Background 1.1 Committees of the Board should submit minutes to the Board. 2. Current Situation 2.1 Draft minutes of the 3 September 2008 to be approved at the next Clinical Governance meeting on 5 November 2008. 3. Conclusion 3.1 The Board is asked to receive the draft minutes. Dr David Price Chair, Clinical Governance Committee 23 September 2008
CLINICAL GOVERNANCE COMMITTEE Wednesday 3 September 2008, 09.00am MacDonald Education Centre, The Ayr Hospital 1.0 ATTENDANCE 1.1 Present: Dr David Price, Chairman Clinical Governance Committee Mrs Kirsty Darwent, Non Executive Board Member Mr David O Neill, Non Executive Board Member 1.2 In Attendance: Dr Robert Masterton, Executive Medical Director Mrs Fiona McQueen, Executive Director of Nursing Mrs. Jacky Williams, Clinical Effectiveness Manager, item 5 Mrs Ada McMeekin, Personal Assistant (Minutes) 1.3 Apologies: Dr. Wai Yin Hatton, Chief Executive Mr John Dever, Non Executive Board Member Ms Elaine O`Connell, Non Executive Board Member Mr Stuart Hislop, Chair Area Clinical Forum 2.0 MINUTES OF MEETING HELD ON 2 nd JULY 2008 Action The minutes were approved as an accurate record. 3.0 MATTERS ARISING FROM THE MEETING HELD ON 2 nd JULY 2008 Point 3.0 Matters Arising from meeting held 5 March 2008 surgical site hair removal. Dr. Masterton advised that discussions are progressing satisfactorily with Urology Services but that no decisions have been finalised at present. Point 6.0 Imaging Pathway Report As per meeting held on 2 nd of July the committee endorsed the imaging pathway report action plan. Dr Masterton confirmed a continuous monitoring approach was to be used and a follow up report to be presented in January 2009. Point 8.0 Complaints Annual Report Mrs. McQueen confirmed that corrections had been made to typing errors in respect of Patient Complaints 07/08. Point 11.0 Blood Transfusion Update Dr. Masterton advised that the Blood Transfusion Update report has been
forwarded to Health Care Directors to allow them to view the approval process. An outstanding issue has been raised in respect of the training aspect for staff involved. Dr. Masterton agreed to take this forward with Fiona Cutler and Health Care Directors. Point 13.0 Medical Directorate Clinical Governance Annual Report 2007-2008 Dr. Masterton advised that one of the incidents reported in February 2008 had been in respect of Heparin Significant Incident Report Case ID WR21372, that this investigation is ongoing at present and will be completed by the next Clinical Governance Committee Meeting. 4.0 MATTERS ARISING FROM PREVIOUS MEETINGS Nil to note 5.0 PRESENTATION CLINICAL EFFECTIVENESS Jacky Williams gave a presentation outlining the refocusing of Clinical Effectiveness Support Department following the workshop in December last year. (See attached presentation). Concluding the presentation it was noted that Services (Health Care Directors and Teams) will become more involved and drive issues forward. It was felt that Clinical Effectiveness is moving in the right direction and becoming more streamlined. The Committee thanked Jacky for her presentation and asked that she forward to her department the Committees appreciation in respect of the progress and amount of work which has been implemented over such a short space of time. 6.0 SAFER PATIENT INITIATIVE - UPDATE Dr. Masterton introduced the Safer Patient programme report and noted that this report had been submitted to the board for consideration/information. Communication Dr. Masterton advised that progress regarding Plasma screens is being actively pursued. Further discussion is required in respect of display information, animation and voice-overs and work is ongoing for a proposal commitment for the next Clinical Governance Committee meeting. Dr. Masterton agreed to discuss the proposed content with Psychology for guidance/direction and Fiona McQueen agreed to link with the Patient Council and Patient Partnership Forum. Patient experience involvement As previously discussed the Committee gave consideration to occasional patient/carer attendance at Clinical Governance Committee Meetings to tell their stories as a means of aiding service improvement. Mrs. McQueen agreed to invite a staff member who has been involved with a patient incident, to attend and discuss their experience with the Committee at the next Clinical Governance Meeting. Mrs. McQueen also agreed to invite Andrew Moore, Head of Patient and Community Relations to discuss how complaints are processed, the costs associated, and the continuous / FMcQ FMcQ
improvement process of Complaints. 7.0 NATIONAL HAND HYGIENE NHS CAMPAIGN COMPLIANCE WITH HAND HYGIENE AUDIT REPORT Dr. Masterton introduced the fourth hand hygiene audit report recommending continuing support from NHS Ayrshire & Arran to achieve the target for hand hygiene compliance to improve to 90% by November 2008. The most recent audit recorded 94%, but we should not be complacent and strive for further gains. The Committee commended the Hand Hygiene Team for their efforts. 8.0 SERVICE IMPROVEMENT ACROSS NHS AYRSHIRE & ARRAN Mrs. McQueen presented this report outlining the current position/approach to delivering Service Improvements. Following recent meetings with Health Care Directors, Mrs. McQueen feels confident that Ayrshire & Arran are responding satisfactorily and appropriately to complaints. She advised that one Service Improvement considered by Andrew Moore Head of Patient and Community Relations, is a letter to complainants, following a 3-6 month period, as a follow up/progress measure to a complaint. Mrs. McQueen agreed to look for further examples of complaints in relation to the attitude of staff and upheld complaints, and noted that she will discuss further with Dr. Masterton information on Service Improvements taking place at Biggart Hospital. FMcQ 9.0 NHS QIS CLINICAL GOVERNANCE & RISK MANAGEMENT DASHBOARD This is a routine report outlining the current position of the NHS QIS targets. Dr. Masterton noted that following discussions with Directors he has requested that Mr. Kerry Walsh develop a second paper to be more understandable to the Committee. Today s report continues to show slow progress and improvement in scoring. The next NHS Ayrshire & Arran NHS QIS peer review/inspection of standards is in 2010 and Mr. Walsh is coordinating the process. The Committee were advised that quarterly reports are being developed to assist Directors to take responsibility for their own requirements. Dr. Price raised some concerns in achieving a target of 8 within 6 months. Mr. Walsh has been asked to arrange an external review and is progressing this at present. 10.0 REPORT ON INCIDENTS, COMPLAINTS, CLAIMS, LOSSES AND ADVERSE EVENTS (QUARTER 4) Dr. Masterton highlighted that this report on Service Improvements identified as a result of claims is still `work in progress`. A further report will follow in due course outlining activity. The committee agreed that this was a useful report. Report will be distributed to Health Care Directors, Senior Management Team and Executive Management Team for information.
11.0 LITIGATION SERVICE IMPROVEMENT REPORT Dr. Masterton presented the Report and noted that a fuller litigation report will be available for the next Clinical Governance Committee meeting. Report noted. 12.0 PROPOSED ROLLING PROGRAMME 2009 Dr. Masterton introduced the proposed 2009 rolling programme for approval. The Committee agreed that the format of the programme is appropriately sectioned by directorate and appreciate that major issues are included, however have some concerns in respect of the volume of items. Dr. Masterton noted that items such as the Imaging Pathway Report are included in a stand alone spreadsheet administered by Mr. Walsh and that he will provide a report for the next Clinical Governance Meeting outlining the current status of items. 13.0 ADVERSE EVENTS POLICY The amended Adverse Events Policy was presented for approval and implementation. Dr. Masterton noted that this policy has been piloted as suitable in respect of Mental Health Services, has already been through the appropriate approval process and has a template for completion. The Committee approved the report. 14.0 KEY PERFORMANCE INDICATORS FOR CLINICAL GOVERNANCE This report outlines the current performance against agreed key performance targets for 2008-2009. Dr. Masterton noted a satisfactory performance which has improved since previous submissions. As most items are now complete, further ones will be developed as part of continuous improvement. 15.0 ADVERSE INCIDENT REPORT IPCU Dr. Masterton introduced report which outlined an incident in IPCU and subsequent completed action plan including various service improvements. Mrs. McQueen noted that concerns/issues in respect of individual IPCU Staff are being progressed. 16.0 CHILD PROTECTION REPORT Mrs. McQueen presented this report outlining the outcome of inspections of services to protect children. Report developed by Liz Moore; however Child Protection Services are now part of Mandy Yule s remit following the refocusing agenda. The committee felt that this was a good report reflecting a strong position. 17.0 UPDATE OF ROLLING PROGRAMME
The committee agreed that two reports in respect of the rolling programme were not required and that paper 15 had already been discussed under point 12 of the Agenda. 18.0 REVIEW OF CANCER WAITING TARGETS Dr. Masterton introduced this summary of local systems and processes for reporting cancer waiting times compliance, already tabled at Health and Performance Governance Committee. Noted. 19.0 SCOTTISH HIP FRACTURE REPORT This report provides the committee with an overview of the findings of the Scottish Hip Fracture Audit Clinical Decision Making: Is the Patient Fit for Theatre Report. The committee agreed that the report outlines good performance within the terms of the National Audit; however delays meaning not operating within 24 hours is causing some concern. 20.0 SOUTH WEST OF SCOTLAND BREAST SCREENING SERVICE ANNUAL REPORT 07/08 Noted 21.0 ANY OTHER COMPETENT BUSINESS Dr. Price and the Committee noted their appreciation of the format of reports submitted, which were of good quality, distributed timeously and have helped progress Clinical Governance Committee meetings. Dr. Price noted that at a recent Clinical Governance symposium, of the 65 abstracts submitted, only 10 were presented due to time constraints and asked for ideas to promote/publicise the good work of the others. Dr. Masterton agreed to investigate. Dr. Price commented that a Non Executive has not, as yet, been invited to join a Senior Management Walk Round as part of SPI 2. Dr. Masterton agreed to rectify this and will take this forward with Babs Gemmell, Patient Safety Coordinator. 22.0 DATE OF NEXT MEETING Wednesday 5 th November 2008, 10.00 am, MacDonald Education Centre, The Ayr Hospital Signed: Date: