Minutes of the Quality Governance Assurance Committee held on the: 25 October 2017 Safe & Effective Kind & Caring Exceeding Expectation Agenda : 12.4
Minutes of the Quality Governance Assurance Committee held on the: Date Wednesday 25 October 2017 Venue Boardroom, G099, Building 12 Time 2.00pm to 4.00pm Name Role Present: R Edwards (RE) - Chair n-executive Director M Arthur (MA) C Etches (CE) G Nuttall (GN) Dr J Odum (JO) J Vanes (JV) Head of Governance & Legal Services Chief Nursing Officer Chief Operating Officer Medical Director Chairman Apologies: D Loughton Chief Executive J Small n-executive Director T: Committees/QGAC/October 2017 Page 1 of 11
1 1a Apologies for absence Apologies were noted. Declarations of Interest There were no Declarations of Interest. 2 Minutes of Previous Meeting Quality Governance Assurance Committee: RESOLVED: Minutes of the Quality Governance Assurance Committee held on 20 September 2017 were approved as a correct record. 3 Matters arising from the Minutes 6.1 20.09.17 - RE queried an action on page 9 of the action plan. Following discussion, FP is to let JO have the Doctor s name and JO in turn will speak to the Deanery to close. JO informed the meeting that it does not look like this was escalated to the Deanery and we cannot get an update as to whether or not this was closed down with the Doctor at the time. JO advised the meeting of the progress made and reported to the meeting that this Doctor was now a GP. JO assured the meeting that the process has now been tightened since this incident. After discussions RE asked JO to try and make contact with the GP via the Responsible Officer and advise the GP of the RCA which took place during his / her time here. Agreed to close this action. The action log was updated accordingly. 4 Regular Reports 4.1 Integrated Quality & Performance Report September - C Etches & G Nuttall CE presented the Quality section of this report. The meeting was informed that the Trust is keeping at the slightly lower level of complaints in terms of numbers and breaches. The Trust is doing well on the amount of complaints that are breaching in terms of consent. CE was pleased to report that the focus which was put on complaints to ensure that areas had systems / processes in place is now having an impact. Friends and Family Test overall the response rate is significantly higher than the England average. The Trust recommendation rate again is consistently lower, however the graph exaggerates the difference and when the figures are reviewed the gap is relatively small, by about 1% for this month. The Emergency Department FFT Response Rate and Recommendation Rate have shown a slight dip for September. There is a positive reduction in late observations in both Divisions. However, to date neither T: Committees/QGAC/October 2017 Page 2 of 11
Division is within the 5% target. CE discussed with the meeting the graph for late patient moves after 8pm. Following the last meeting the total admissions for the Trust and also the admissions through the ED department had been added. CE asked the meeting if both of the admissions should be left on the report or should the only ED admissions be left on and the scales changed. It was agreed to leave both admissions on the report. Pressure Injury prevalence has gone down but the number of incidents (unavoidable) has increased. CE advised the meeting that work has started to look at the Tissue Viability Strategy as it is now approaching its third year. Safety Thermometer is the highest it has ever been since the start of data collation, 96.5%. CE feels that this has been driven down by the reduced number of patients who fell with any harm. New VTE s has increased significantly with no particular reason. Cardiac Arrests indicate in September that only 2 patients were discharged. VTE assessments look at both the first and second assessments and work has been undertaken on how the data is being collected on the second assessment. CE informed the meeting that the VTE group has been deferred in reporting back to PSIG until vember. There has been a slight increase (3) in falls with harm in September. CE advised the meeting that this figure is significantly better to two years ago. There is now evidence that the new policy and the collaborative approach are having an impact with the arm s length nursing etc. NHSI raised a question in regards to the Trust figures for E Coli cases. CE advised the meeting that the Trust performance is not a problem and that the majority of cases are occurring in the community, and that the responsibility for these lies with the CCGs rather than the Trust. CE reported to the meeting that CPE has already exceeded the 2016/17 number (18), currently there have been 21 cases in this financial year. CE predicated that the Trust will have seen in the region of 40 + cases of CPE. The meeting noted that there were 3 medication incidents (level of harm caused) in September. Investigations have been completed at a local level to understand the root causes and the actions been taken to minimise them from happening again. Serious Incident reporting for September shows some breaches. CE informed the meeting that she believes that the Trust now has an agreement with the CCG again about the timescales for reporting SIs, which will take into account the date when the trust became aware of the incident and will mean the trust will not be fined in future for an unavoidable delay in reporting. There has been a slight increase in radiation incidents and this is being monitored over the next few months to see if there is a trend or a one off. The training for Safeguarding Adults and Children is above the 85% national target but the Trust has still not hit its own internal target of 95%. CE advised the meeting that the reason for the internal target not being achieved may be due to Junior Doctors not being removed from the list when they leave the Trust, and agreed that this may also be affecting other training performance figures. T: Committees/QGAC/October 2017 Page 3 of 11
CE informed the meeting that 5 full-term babies had been admitted to the Neo Natal Unit, this appears concerning but it is normal. C-Section rate has come down but it is still above the target. The Midwife to Birth ratio is up at 1:32, CE assured the meeting that it is not due to an increase in vacancies in Maternity, but the birth numbers going up against the numbers of Midwives. In response to a question from RE she said that the Trust is responding to the raised birth numbers by a combination of recruitment of midwives and containing the numbers of mothers coming to the Trust. The Trust's recruitment of Midwives continues to be successful. JO commented that the number of early neonatal deaths stood out, but pointed out that all but one were less than 24 weeks gestation and this one had multiple deformities. GN presented the Performance section of this report. GN informed the meeting that cancelled operations for non-medical reasons remains green and following a recent FOI, this Trust was one of the few Trusts to have a positive trend. Referral to Treatment times saw a slight deterioration in September but was steady in >52 weeks and diagnostics. GN assured the meeting that based on the current forecast predictions have been made that the Trust will be back into trajectory by the end of March. GN advised the meeting that September s A&E 4 hour waiting time performance for the Trust was lower than normal at 86.44%. Beds were an issue and our admission rate did increase. Ambulance conveyances increased by 2%. GN reported that Vocare has a CQC visit on Thursday 26 October. In response to a question from RE, GN said that the Trust's working relationship with Vocare was good and that there were good discussions at clinical level, with some diversion of cases down from Vocare, for example paediatrics. GN said that a long discussion and debate on Cancer Targets had been held in Finance & Performance. For quarter 2 the Trust will be at 75% / 76%. The Trust have been asked to submit a revised trajectory that says we will achieve 85% by the end of March, GN feels this will be a challenge for a number of reasons (capacity issues, changes in other cancer pathways that may affect us and issues within other organisations). GN to add to the report a local measure of average waiting times, which will show how long people are waiting and give a better indication of whether or not things are improving. The meeting was advised that the Trust has been above the NHS e-referral target line for online appointment slots and has been incurring fines for the last 12 months. There will be greater focus on this target in future, as this will link to a national CQUIN about going paperless. The areas facing the biggest challenge were Ophthalmology, Orthopaedics, JO Neurology and Dermatology. Delayed Transfers of Care are going in the correct direction for Wolverhampton. This was discussed in depth. The meeting agreed that for delayed transfers of care, figures for Wolverhampton and Staffordshire should be given separately." and put an action on Gwen. RE asked if there was any reason why the issuing of discharge letters from assessment units had decreased against the Trust's new target which we have been meeting for the last few months. GN replied that there was nothing specifically in terms of September but this report does fluctuate. GN T: Committees/QGAC/October 2017 Page 4 of 11
JV asked if the 80% target for annual appraisals is our own target or a national target, agreed in the meeting that it is our target. JV raised concerns about the Primary Care appraisal rates. This was discussed and it was agreed that JO would speak to Sultan Mahmud to clarify. Resolved: Report was accepted 4.2 Board Assurance Framework / Trust Risk Register M Arthur Board Assurance Framework Key Issues 0 new risks 4 red risks SR1 - Workforce - Recruitment and Retention of staff across the Trust and in particular the future pipeline of nursing and medical staff SR8 - That there is a failure to deliver recurrent CIP's. SR9 - That the underlying deficit that the Trust has (in 2017/18) is not eliminated in medium term to bring the Trust back to financial surplus. SR10 - That the Trust fails to generate sufficient cash to pay for its commitments. CE asked if there was any reason why the BAF comes to every meeting and the Trust Board bi-monthly. The meeting agreed that there has been little movement in the BAF since the previous month and considered whether it should see the BAF bi-monthly. Following discussion it was agreed that even though the BAF moves less, there is always movement on the risk register and that scrutiny and discussion of the register is required. Trust Risk Register Key Issues 2 new risks: 4841 - Risk of CPE becoming endemic in clinical areas (CNO) 4862 - Increase in demand for Neonatal cots at level 1, 2 3. (COO) 0 risks removed 5 red risks: 2080 - Risk to quality of patient care: reduced manpower (COO) 4661 - Lack of robust system for review and communication of test results (MD) 4472 - Delays in Cubicle Assessment and Triage (COO). 4113 - Division 1 failure to achieve CIP target (COO) 4866-1.362m risk in the income plan (CFO) Risk 4286 RE noted the intention to work with others and sought confirmation that this action was progressing. GN replied that there is nothing further to be done on this risk and the risk is up to date. Risk 4523 RE queried if this risk would be sorted by December or January. GN confirmed that it will be. Risk 4596 RE sought confirmation that this risk was moving ahead and working with others. GN confirmed that a lot of work had gone on and another meeting was taking place at the end of vember to pick this up. This will be a long term risk. T: Committees/QGAC/October 2017 Page 5 of 11
Risk 4599 RE commented that the Emergency Services seemed overwhelmed by the number of issues requiring action. GN replied that there was a spotlight on the Emergency Department and their Governance processes. GN, JO and CE are involved in this risk and GN confirmed that the Emergency Department is getting on top of it now. JO gave a detailed update on this risk and how the Emergency Department will be supported in achieving the transactional period. Risk 4718 RE sought clarification that this will be updated and removed from the register. CE confirmed that this was correct and Fiona Pickford has updated the risk and the changes will be seen by next month. Risk 4375 / 4411 Fire Safety RE commented on the issues raised within the risks regarding compartmentation. The meeting discussed on risk 4411 if the word planet was correct or if it was a typo error. GN to confirm and report back via e-mail after the meeting. Resolved: Report was accepted 5 Sub Group Reports 5.1 Chairman s Report PSIG September Dr J Odum Risk Assessment Regarding Management of Dysphagia An outstanding item from the nutrition support steering group relates to risk assessment of swallowing competency for dysphagic patients at weekends and bank holidays when the speech and language therapists are not available. Competency of training of nursing staff to undertake these assessments remains outstanding. It is proposed that swallowing assessments be undertaken by nurses competent to undertake these assessments, by virtue of them performing this on a regular basis (for example stroke nurses) in the absence of speech and language therapists, until such a time as the competency training programme is established and agreed. The divisional nurses will review the process to be taken and report back to PSIG. Ward Performance Monitoring Reports Good progress continues to be undertaken generally across the metrics assessed by the dashboard, including patients with serious harm following a fall and pressure injury management. Serious Untoward Incident Report Good progress has started to be made with reducing the numbers of overdue actions and there will be a focus on reducing the numbers of outstanding corporate actions. The Commissioners continue to raise a number of queries relating to signed off root cause analysis by the Trust. In an attempt to reduce the number of queries raised by the CCG PSIG has agreed that a CCG representative may attend the divisional RCA table top, but it must be explicit that the CCG representative attending the table top is appropriate for the nature of the RCA investigation being discussed and should have the necessary skills and training to understand the detail of the investigation being presented. GN T: Committees/QGAC/October 2017 Page 6 of 11
5.2 Patient Experience Group (Quarterly Report) A positive report was presented highlighting a reduced number of formal complaints received in Q1 2017/18 (compared to Q4 2016/17). Also for Q1 2017/18 for the 115 cases closed 95% were closed within 30 days or consent to breech was sought, with 5% being closed over 30 days with no consent to breech being sought. Resolved: Report was accepted. Patient Safety Improvement Group minutes - September The meeting accepted the minutes from the September meeting. 5.3 / 5.4 Chairman s Report QSAG September 2017 / Quality Standards Group minutes September September s QSAG meeting was postponed due to the lack of reports submitted. 6 Assurance Reporting / Themed Reviews There are no assurance reporting / themed reviews for October. 7 SUMMARY OF SIGNIFICANT ISSUES Integrated Quality and Performance Report - Scrutiny of grade 2 pressure injuries - Safeguarding training and impact on figures of junior doctors not being removed from lists - Maternity and midwife ratio - NHS e-referrals Board Assurance Report and Trust Risk Register QGAC considered whether it should see the BAF less frequently, but agreed that while the BAF might move less, there was always movement at the TRR level and that scrutiny and discussion of TRR was required. Some risks required revision to reflect the improved current position, and there will be a process over the next two months of stripping out the older, superseded evidence. Chair s Report from Patient Safety Improvement Group meeting 15 September 2017 A report on Surgical Checklist and progress with NATSSIPs and LOCSSIPs and human factors initiatives will come to PSIG in vember and if suitable will come to QGAC as a themed review. Ward Performance Monitoring Reports: good progress continues generally across the metrics assessed by the dashboard, including patients with serious harm following a fall and pressure injury management. Serious Untoward Incident Report: good progress has started to be made with reducing the numbers of overdue actions and there will be a focus on reducing the number of overdue T: Committees/QGAC/October 2017 Page 7 of 11
corporate actions. In an attempt to reduce the number of queries from commissioners about root cause analyses by the trust, PSIG agreed that a CCG representative may attend the divisional RCA Tabletop, on the basis that the CCG representative has the skills and training to understand the detail of the RCA being presented. Matters for Audit Committee - There were none 8 Evaluation of Meeting ALL Quorate, good meeting, on time. 9 Any Other Business ALL CE reported that there has been a potential Never Event in Maternity and there will be an update at the next meeting. RE asked JO about the letter received from NHSI in regards to Mortality and the Trust being kept under scrutiny. JO explained that scrutiny would continue until the Trust SHMI and HSMR are back to the average level. 10 Date and time of Next Meeting: Wednesday 22 vember 2017 2pm, Boardroom, G099. T: Committees/QGAC/October 2017 Page 8 of 11
COMMITTEES ACTION SUMMARY REPORT ITEM 4.1 25.10.17 to be taken raised from the meeting GN to add to the report local target, this will show how long people are waiting (Cancer Waiting Times) Lead Committee Review Date date GN 25.10.17 22.11.17 Update 4.1 25.10.17 4.2 25.10.17 JV raised concerns about the Primary Care appraisal rates. This was discussed and it was agreed that JO would speak to Sultan Mahmud to clarify. The meeting discussed on risk 4411 if the word planet was correct or if it was a typo error. GN to confirm and report back via e- mail after the meeting. JO 25.10.17 22.11.17 GN 25.10.17 22.11.17 GN confirmed via e-mail after the meeting that Planet is the Estates Maintenance programme. Drax is the system used to transmit fire alarms to switchboard 4.2 20.09.17 RE asked for an update on risk 4286. TP was unable to comment due to it being a Division 1 issue. RE asked about DNA rates and what could be done to reduce them and CE advised that adolescents have a very high DNA rates. After a brief discussion, it was agreed to raise this risk with GN. GN 20.09.17 25.10.17 22.11.17 Bring forward to the next meeting at the request of GN. 4.2 20.09.17 RE mentioned that risk 1713 does not reflect the much more positive information about the steps being taken which was given at Audit Committee. JO agreed to update this risk. JO 20.09.17 25.10.17 22.11.17 Bring forward to the next meeting at the request of JO. T: Committees/QGAC/October 2017 Page 9 of 11
Closed Agenda s To be removed at the next meeting ITEM to be taken raised from the meeting Lead Carried forward from Committee Review date Update 6.1 20.09.17 4.2 20.09.17 RE queried an action on page 9 of the action plan. Following discussion, FP is to let JO have the Doctor s name and JO in turn will speak to the Deanery to close. RE asked about risk 3069 and the number of never events, noting that there were never events in June and August. RE asked what more could be done. FP / JO 20.09.17 25.10.17 update in section 3 of the minutes - CLOSED CE 20.09.17 25.10.17 CE advised the meeting that at the next PSIG meeting there will be a report on WHO checklists and NATSIPPS. CE suggested that this report will come to the vember QGAC meeting. CLOSED 6.1 26.07.17 MA to provide further information about the process of reaching judgments to QSAG and to discuss at QSAG the scope for any changes. MA 26.07.17 20.09.17 25.10.17 PA to speak to MA for an update and e-mail Minute Taker to circulate Response: The question of consistent and appropriate CQC selfassessment judgements was raised at the July QSAG meeting (detail discussion can be seen in the minute). The members were reminded of the current process for sign off of Core Service ratings (via Divisional Quality Performance reviews) and for Fundamental standards of care (FSC) (via subject leads approved by the relevant group/manager/exec). There were no additions suggested to the current sign off process, but it was acknowledged that perhaps there needed to be further consideration/challenge of ratings of good with outstanding actions vs requires improvement which would indicate fundamental gaps. This level of questioning/further challenge would be the role of the Divisions (for Core Service judgements), T: Committees/QGAC/October 2017 Page 10 of 11
FSC leads, specialist groups/manager/exec (for FSC judgements) and ultimately QSAG; before an assurance report is sent to QGAC. I will ensure this message is taken back to these sources to prompt this challenge. 4.2 / 27.06.17 4791 - Unplanned activity leading to financial pressures (CFO). GN questioned one of the examples given the risk manifesting itself and would speak to Kevin Stringer about it. GN 21.06.17 26.07.17 20.09.17 CLOSED GN informed the meeting that she had spoken to Kevin Stringer about the risk. GN is waiting for a reply from Kevin and will feedback at the next meeting. TP to speak to GN and bring forward to the next meeting. 25.10.17 GN confirmed that she has spoken to Kevin Stringer and Kevin as agreed to review CLOSED 4.2 20.09.17 Risk 4375 RE asked if this risk could be updated as there are a number of zeros / 0. GN 20.09.17 25.10.17 Confirmed as partly updated. CLOSED 4.2 26.07.17 3256 - Audiology at West Park: UKAS accreditation was withdrawn in May 2017 and plans for relocation are remote. It was agreed that this risk and the controls need a complete review. GN 26.07.17 20.09.17 25.10.17 PA advised the meeting that GN may have reviewed as the score has been downgraded. Following a brief discussion, TP to speak to GN and bring forward to the next meeting. Removed from the Risk Register - CLOSED T: Committees/QGAC/October 2017 Page 11 of 11