1 Minutes QSE Public 9.5.17 V1.0 Present: Quality, Safety & Experience (QSE) Committee Minutes of the Meeting Held on Tuesday 9 th May 2017 in the Boardroom, Carlton Court, St Asaph Mrs Margaret Hanson Ms Jenie Dean Mrs Lyn Meadows Independent Member (Chair) Independent Member Independent Member In Attendance and Observers: Mrs Kate Dunn Mrs Fiona Giraud (part meeting) Mrs Gill Harris Ms Jackie Hughes Mrs Barbara Jackson Dr Jill Newman (part meeting) Ms Morag Olsen Miss Teresa Owen Professor Michael Rees Mr Adrian Thomas Mr Mark Thornton Dr Mark Walker (part meeting) Acting Head of Corporate Affairs Head of Midwifery & Women s Directorate Executive Director of Nursing & Midwifery Staff Side Chair Deputy Director of Contractor Services Director of Performance Chief Operating Officer Executive Director of Public Health Healthcare Professionals Forum Chair Executive Director Therapies & Health Sciences Vice Chair, Community Health Council Deputy Medical Director Agenda Item QS17/76 Chair s Opening Remarks Action By The Chair welcomed everyone to the meeting. She reported that Chair s Action had been taken to approve the Committee Annual Report for 2016-17 on behalf of the Committee, as previously agreed. QS17/77 Declarations of Interest None declared. QS17/78 Apologies for Absence Apologies were received from Cllr Cheryl Carlisle, Mr Chris Wright and Dr Evan Moore. QS17/79 Minutes of Meeting Held on 29.3.17 for Accuracy and Matters Arising from the Summary Action Log
2 Minutes QSE Public 9.5.17 V1.0 QS17/79.1 The minutes were approved as an accurate record. A matter arising was raised regarding patient stories, in terms of the follow up of a specific story from July 2016 and plans to consider how best to share patient stories with the Committee. Dr Mark Walker and Mrs Gill Harris would take this forward. MW QS17/79.2 Updates were provided to the summary action log. QS17/80 Improving the Care of Older People in North Wales, Older People s Commissioner Recommendations and Health & Care Standards Assurance QS17/80.1 Mrs Gill Harris presented the report which she noted was a more blended approach which brought together a range of strands of related work including Community Health Council reports, Healthcare Inspectorate Wales report and the Older People s Commissioner Framework) to scrutinize services for older people through a single lense to assess performance and identify areas for improvement. She indicated that the paper provided a baseline of activity within BCUHB and set out to align this with elements of the Quality Improvement Strategy. She highlighted sections within the paper relating to falls prevention, pressure ulcers, support to care homes, development of a dementia strategy and work ongoing to develop a Harms Dashboard. QS17/80.2 Mrs Margaret Hanson asked members for their views on the format of the report and the Committee were broadly supportive of the approach, welcoming the overview that the report provided across all aspects of older people s services and the ability to identify and develop themes. It was suggested that the report could be further improved by inclusion of some elements from a Public Health Wales perspective such as screening, and by looking to strengthen the integration between secondary and community care. The comment was made that this type of blended report could be applied to other areas such as children s services. QS17/80.3 A discussion ensued with members making a range of comments regarding older people s services and how their care could be improved within BCUHB. These included focusing on the totality of care; ensuring that older people and their families felt able to raise questions and concerns with the healthcare professionals who were treating them; the provision of health advice and information which was clear and well understood; ensuring that cross border treatment met the same standards; the provision of systems and processes that maximised the best use of nursing time with patients. This last point was highlighted as having been raised through the staff survey in that 52% of responders had felt they were unable to meet all patient needs with lack of time being a recurring factor. With regards to the reported health and care standards, further explanation was sought as to why there was a marked reduction in the score for people s rights in the Individual Care domain. QS17/80.4 The question was asked as to how often the Committee could expect to receive such a report and it was suggested this should be at least twice per year with additional data being reported through the dashboard. Mrs Hanson requested that the next report incorporate some of the feedback from the older people s strategy development.
3 Minutes QSE Public 9.5.17 V1.0 QS17/81 Prevention of Patient and Visitor Violence QS17/81.1 Dr Mark Walker presented the paper which outlined a project being undertaken by Professor Lepping to prevent patient and visitor violence incidences on hospital site. The project would review and consider a range of evidence and define a strategic approach for the organisation, within a timeframe of reporting back to the Committee in October 2017. QS17/81.2 The Independent Member who was also the Violence and Aggression (V&A) champion highlighted that this was a complex area and felt that the organisation should be undertaking appropriate specific risk assessments, as opposed to these being part of a generic ward risk assessment. She also sought assurance as to the appropriateness of the V&A training currently provided. She referred to findings within the staff survey that 42% of responders felt that V&A was not well managed within BCUHB, and to trade union concerns over specific cases and the organisation s ability to provide the right type of support for individual members of staff. She requested that consideration be given to a wider piece of work into V&A management in conjunction with the prevention aspects covered in the remit of Professor Lepping s work. QS17/81.3 Mrs Margaret Hanson requested that when the outcomes of Professor Lepping s work were presented, these also include a service improvement focus and be supported by a wider paper on V&A management. The relevant Executive Directors would be asked to identify the best way to initiate this piece of work. EM MO QS17/81.3 The Committee noted the report. QS17/82 Integrated Quality & Performance Report QS17/82.1 Ms Morag Olsen introduced the report, highlighting it had been prepared from March data. She indicated that data quality issues remained following the migration to a new patient administration system in Ysbyty Glan Clwyd, and also that a backlog of coding was likely to affect the data. The relevant Executive Leads then summarised key points from the various domains. QS17/82.2 Staying Healthy Emergency admissions performance was being maintained. Further work was required to address the readmissions performance. National and local influenza debriefings had taken place to share good practice and to target areas for improvement for the next flu season. Reporting of childhood immunisation data would be changing based on the new delivery framework. There was a need to maintain consistent and ongoing messages to the public rwith regard to immunisations, with a measles outbreak in Europe being cited. QS17/82.3 Safe Care There was a need to ensure sites and staff understood the requirements for reduction in harms through hospital acquired pressure ulcers, and this would be supported by the developing dashboard approach. Falls prevention was now supported by a baseline and a strategy.
4 Minutes QSE Public 9.5.17 V1.0 The three open Regulation 28 cases in the report had now been closed. QS17/82.4 Effective Care The impact of effective job planning upon the follow up issue was noted. An explanation was provided as to how the coding backlog affected mortality rates in that this related to number of anticipated and non-anticipated deaths. It was noted that a paper on mortality was scheduled for the July Committee meeting and this should include the mortality review process. The Chair had also requested a board development session to ensure a shared understanding of how mortality rates were calculated. Assurance was provided that any concerns arising from mortality data would be picked up at the mortality group and escalated to Quality Safety Group who would flag with the Committee as appropriate. It was confirmed that additional coding staff had now been appointed. QS17/82.5 Individual Care With regards to patients leaving Emergency Departments (EDs) without being seen, performance was positive. There was also evidence from a survey undertaken at the Wrexham Maelor Hospital that those patients who did leave did not then go on to be seen elsewhere, therefore, messages and campaigns about the appropriate use of EDs continued to be important. The iwantgreatcare pilot remained fairly static. Delayed transfers of care continued to be experienced mainly due to availability of care home provision. It was clarified that in-patient experience was measured via a monthly questionnaire which had reasonable response rates, however, there was an intention to focus more on out-patients and to utilise real time touch button kiosks. Recurring themes were around waiting times, staff attitude, Welsh language and access. A plan to improve response times to complaints by September 2017 was reported, and the Committee were informed of significant staff absences both within the divisions and the corporate team. Revised management arrangements would also need to be implemented and bedded in and it was suggested that the opportunity be taken to have further discussions around the model of complaints management. The CHC would be willing to participate in these discussions. QS17/82.6 The Committee noted the report. [Dr Mark Walker left the meeting] QS17/83 Infection Prevention & Control Report [Ms Morag Olsen left the meeting] QS17/83.1 Mrs Gill Harris presented the report, drawing members attention to the key exception issues around the norovirus outbreak in Wrexham Maelor and the influenza case in Ysbyty Glan Clwyd, which had been areas of concern for the Committee previously. She assured the Committee that the Hospital Management Teams were working with key clinicians and Public Health Wales to review the outbreaks and looking more widely at all incidences of infection over a set period of time. There was also involvement with the estates team.
5 Minutes QSE Public 9.5.17 V1.0 QS17/83.2 A discussion ensued regarding engagement and clinical leadership. It was acknowledged that infection prevention and control was essential for any healthcare worker irrespective of professional group. The specific issue of consultant microbiologist and medical scientist roles continued to be followed up with Public Health Wales by the Executive Nurse and Medical Directors. It was also noted that comparison with England was not always helpful as there were mandates within England that were not in place in Wales, and which clearly impacted on infection prevention. [Dr Jill Newman joined the meeting] QS17/83.3 A discussion took place regarding overall progress with infection prevention and control over several years, as many of the historical challenges were still being faced. The progress made was acknowledged and it was felt that there was now a very strong clinical voice at Executive Team level, however the Committee were very much aware that as an organisation BCUHB was not where it needed to be in terms of infection prevention and control performance. A shared responsibility across all healthcare professionals was essential. Mrs Margaret Hanson also suggested that a future IQPR report include more information on antibiotic prescribing and proton pump inhibitor models. QS17/83.4 The Committee noted the report and requested that at a future meeting, representatives of the hospital teams be asked to attend to highlight the progress made as part of a more in-depth look at infection prevention and control. MO (JN) QS17/84 Annual Quality Statement (AQS) QS17/84.1 Mrs Gill Harris presented the draft AQS noting there was still considerable work to be done. Ms Jenie Dean confirmed that she had been involved in the editorial panel as the Committee representative and the document had been substantially updated and amended over the past month. The panel had received support from the communications team with regards to reducing the size of the document whilst retaining the key messages. Ms Dean was also aware that a follow up meeting was being arranged with the Community Health Council (CHC) for their input, and that she was meeting again with the author. She therefore requested any further comments from members to be copied to both Alison White and herself. QS17/84.2 The Committee noted the progress made but would wish to receive assurance that comments made have been included, the infographics element finalised and that the CHC had input into the process. [Ms Morag Olsen rejoined the meeting] QS17/89 National Delivery Framework 2017-18 [Taken out of order at Chair s discretion] QS17/89.1 Dr Jill Newman presented the report which provided an update on the publication of the National Delivery Framework 2017/18 and the actions being taken to implement this into the Health Board s Integrated Quality & Performance Report (IQPR) and performance assurance reporting. She explained the intention to align the strategic direction with legislative requirements but that unfortunately the framework was not
6 Minutes QSE Public 9.5.17 V1.0 published by Welsh Government until after the Board have approved its Annual Operational Plan (AOP). She reported there was a need to incorporate a range of new indicators, each of which required the identification of an Executive sponsor, a named management lead and an exception report lead. Dr Newman shared her personal view that many of the indicators relied on information reported externally on an annual basis, and that she would wish to ensure internal processes were in place to allow the Board to assess its current position and performance against any indicator at any given time during the year. When questioned regarding the timeframe, Dr Newman indicated she would hope to have the leads in place by the end of May together with a baseline assessment, with the first results being incorporated into the June IQOR. QS17/89.2 In response to a question regarding the monitoring of the AOP, it was confirmed that those targets were committed to and would be tracked on a local basis, although some would be through the Finance & Performance Committee for example out-patient did not attend rates. It was also noted that a thematic report to the Committee on follow ups was being prepared. QS17/89.3 The Committee noted the report. [Dr Jill Newman left the meeting] QS17/87 Women s Service Assurance Report [Taken out of order at Chair s discretion] QS17/87.1 Mrs Fiona Giraud presented the quarterly report which aimed to provide assurance around the monitoring arrangements in place for Women s Services across BCUHB. She highlighted that overall agency use was now down to 16% from the 50% rate at the time the Board was placed in special measures, and that 10 of the 12 resident consultant posts had been recruited to with the remaining 2 due to be advertised. There were no vacancies within medical and nurse staffing and as a consequence reliance on agency had significantly reduced. QS17/87.2 Mrs Gill Harris made reference to a recent event with student midwives and that there was a tangible improvement in positivity about a career in women s services in North Wales. Mrs Giraud reported that the first group of students had been placed back on the Ysbyty Glan Clwyd site and this was proving positive to date, although there was close monitoring in place. In addition, Mrs Harris referred to an exercise by the communications team to seek feedback from service users as part of the International Day of the Midwife to which there had been a very good response. The Committee would be provided with a summary of the feedback. QS17/87.3 Mrs Giraud confirmed that the Health Board were currently working with an external company with regards to the development and implementation of an organisational development (OD) plan for maternity services which would be a blended approach with the Board s own Workforce & OD team. Proposals would need to be considered by the Executive Team in the first instance, but there was positive feedback that the consultant body were keen to get involved in this piece of work. It was suggested that improvements to job planning performance would also impact positively upon culture within teams and units, and Prof Michael Rees would be invited to participate in planned meetings between the women s directorate and the Head of Medical Workforce. FG
7 Minutes QSE Public 9.5.17 V1.0 A discussion ensued. With regards to the identification of themes, it was confirmed that any trends were identified via a monthly reports, with a lessons learnt bulletin being issued. Exception reporting would be made through the Quality Safety Group (QSG). With regards to longer term sustainability of medical rotas, it was reported that the current situation was stable but recruitment and retirements would impact on the future ability to sustain rotas. The point was made that the way in which mandatory training compliance had been reported within the paper did not help members identify if there were any areas of concern. Mrs Giraud would circulate a briefing note with the latest position. FG QS17/87.4 The Committee noted the report. QS17/85 Continuing Health Care Quarterly Update Report QS17/85.1 Mrs G Harris presented the paper which provided the Committee with a quarterly performance report and an update on local and national issues and risks associated with Continuing NHS Health Care. She highlighted that an annual self assessment had been submitted as part of the performance framework which had identified some areas for development. It was confirmed that the process for dealing with retrospective claims had been established and improvements could be seen in the pace of resolution. Key risks were highlighted to the Committee around the timeliness of completing chronologies, access to records in storage, timely recruitment and the flow of completed cases, with assurance provided that there were mitigations against the risks. The Committee had previously expressed concerns around the availability of nursing home placements and associated staffing issues, which continued. Mrs Harris drew members attention to the mitigating actions that were being taken in response to these concerns. QS17/85.2 A question was asked whether the actions detailed within Appendix 3 following the self assessment had been completed, and Mrs Harris would seek an update outside of the meeting. She also undertook to clarify whether Table 1 related to the number of applications received. QS17/85.3 The Committee noted the report. QS17/88 Nurse Staffing in Secondary Care QS17/88.1 Mrs G Harris presented the paper which provided an overview of the BCUHB approach activity in setting, reviewing and monitoring acute ward nurse staffing levels. She confirmed that the organisation would be monitoring adherence to the Act through the safe care module of the allocate rostering system which enabled real time information of staff on duty at any one time. It was noted that a stock take exercise was undertaken in December 2016 but there had been gaps in the data collection. Mrs Harris indicated that a recommended uplift was being built into BCU establishment in line with the Chief Nursing Officer (CNO) requirements. There were 203 vacancies across the acute sector currently, which were being mitigated. QS17/88.2 A discussion ensued. It was requested that the approach for assessing staffing levels in relation to other professional groups be considered, as a recent report to the Healthcare Professionals Forum had indicated concerns over the number of
8 Minutes QSE Public 9.5.17 V1.0 therapy graduates. Mrs Harris stated that a wider piece of work with a community focus was needed, and it was suggested that the Strategy, Partnerships & Population Health (SPPH) Committee would need to pick this up as part of the monitoring of the Integrated Medium Term Plan (IMTP). In response to a question around the consequences of failing to comply with the requirements of the Act, Mrs Harris confirmed that the CNO had been asked to clarify sanctions. QS17/88.3 The Committee noted the report. QS17/90 WHC2017/008 Policy for Repatriation of Patients Noted. QS17/91 Issues Discussed in Previous In Committee Session Noted. QS17/92 Documents Circulated to Members The items listed as having been circulated since the last meeting were noted. QS17/93 Issues of Significance to Inform the Chair s Assurance Report Following the meeting, the issues below were agreed with the Chair: Continued concern that infection prevention and control continued to be a challenge, despite demonstrable progress. The Committee would wish to meet with hospital team representatives to better understand the improvements made and further challenges. The Committee were supportive of the approach to a blended report encompassing older people s services, commissioner recommendations and healthcare standards - welcoming the overview that the report provided across all aspects of older people s services and the ability to identify and develop themes Information on a study relating to prevention of patient and visitor violence was received, and Executives were requested to identify a wider piece of work on violence and aggression management. As part of the quarterly assurance report into women s services, the Committee were informed that the Health Board were liaising with an external company with regards to the development and implementation of an organisational development (OD) plan for maternity services which would be a blended approach with the Board s own Workforce & OD team. Proposals would be considered by the Executive Team in the first instance. The Committee had previously expressed concerns around the availability of nursing home placements and associated staffing issues. The paper set out a range of mitigating actions that were being taken in response to these concerns. A paper on Nurse Staffing in Secondary Care was received with an indication that a wider piece of work with a community focus and consideration of other professions, eg therapy, was needed. The Committee suggested that the SPPH Committee would need to pick this up as part of the IMTP monitoring.
9 Minutes QSE Public 9.5.17 V1.0 QS17/94 Any Other Business None raised. QS17/95 Date of Next Meeting 6.6.17 at 9.30am in Carlton Court. QS17/96 Exclusion of Press and Public The Committee then met in-committee.