OPERATIONAL DIVISION MINUTES OF THE OPERATIONAL DIVISION RISK MANAGEMENT GROUP MEETING HELD AT 3.00 PM ON THURSDAY 23 MAY 2013 IN THE BOARD ROOM, HAYFIELD CLINIC, VICTORIA HOSPITAL Present: Mrs M Henderson (MH), Divisional General Manager Ambulatory Care (Chair) Mr B Gillespie (), Head of Estates Mrs J Mercer (JM), Legal Services Manager Mrs P A Cumming (PC), Risk Manager, NHS Fife Ms. S Fraser (SF), Divisional General Manager Planned Care Ms. E Connolly (EC), Directorate Nurse Manager Emergency Care Mr K Anderson (KA), ehealth Delivery Manager, NHS Fife Mr B McKenna (BMcK), HR Manager Mr D Livingstone (DL), Infection Control Manager Apologies: Mr G Cunningham (GC), Director of Acute Services Ms. J Owens (JO), Depute Director of Nursing Mrs D Clark (DC), Acting Health & Safety Team Leader (OHSAS) Dr G Birnie (GB), Medical Director Ms. C Stewart (CS), Directorate Accountant Mr S McGlashan (SMcG), Microbiology Service Manager Mrs M Ross (MR), Directorate Manager Medical Director Mrs C Duncan-Farrell (CD-F), Head of Physiotherapy In Attendance: Mrs G McKinnon (GMcK), Personal Assistant to Director of Acute Services 1 APOLOGIES Apologies noted above. 2 MINUTES OF MEETING 24 JANUARY 2013 The Minutes of the Meeting held on 24 January 2013 were accepted as an accurate record. 3 MATTERS ARISING: 3.1 Risk 2642: Compliance with EWTR PC advised she had followed this risk up with Rona King, Gordon Birnie and Brian Montgomery who felt this risk has moved/ 1
moved on. It was agreed that a new risk should be develop regarding staffing rotas. PC will provide a rationale to close off risk 2642. PC 3.2 Risk 951: Medical Staff - Equipment PC advised this risk has been updated but should still remain on the register. 3.3 Risk 955: Medical Staff Performance PC advised this risk has been updated but should still remain on the register. 4 DIRECTORATE RISK REPORTS: 4.1 Planned Care The Group noted the Planned Care Directorate Risk Report, and SF advised there had been a number of risk registers held within the Directorate and these have been consolidated into one risk register for Planned Care. SF advised the key risks on the Planned Care Risk Register are delivery of treatment time guarantee; continuation of medical boarders in surgical wards; and continued reliance on medical locums. SF advised 3 new risks have been added to the Planned Care Risk Register and there continues to be a financial risk in relation to the overspend position of the Directorate. SF referred to Risk 3096 and the manual handling risks associated with transporting patients up and down the gradient from Ward 5 ENT Unit to the Theatre Suite Phase 3, VHK. It was noted this corridor was not only used by Planned Care staff, and the risk may be an operational one. Following discussion to check the position regarding this risk. SF advised DatixWeb is being implemented and rolled out across the Directorate which will enable new incidents to be monitored and actioned in a more robust and timely manner. 4.2 Human Resources The Group noted the HR Directorate Risk Report, and BMcK advised the key risks within the Human Resources Directorate were in relation to the capacity of the HR Department and OHSAS service to meet future NHS Fife priorities; the diversity of the current workforce to meet the requirements of future demands; and knowledge base of managers across NHS Fife on/ 2
on HR policies and procedures. BMcK advised there have been a number of key actions taken to reduce and eliminate identified risks. BMcK advised risks are being managed within the Directorate. BMcK advised there has been progress in relation to absence management rates, and the February March figures looked more promising. The pre-employment health screening process is currently being reviewed with the intention of simplifying this process. BMcK advised in line with the SEAT Chief Executive agreement, a risk assessment is being carried out in 5 areas, which have been identified as being a priority. These are Anaesthetics, ICU, Emergency Medicine, Paediatrics and Obs & Gynae. These risk assessments, incorporating the trained, trainee and non-medical functions. The Protection of Vulnerable Groups (PVG) commenced last year and being rolled out within the Operational Division. eess will initially be rolled out to HR and Finance Directorates, before being rolled out to other services. This will give a far better indication of staff who are up to date with training. 4.3 ehealth The Group noted the ehealth Directorate Risk Report, and KA advised due to the nature of information technology there would continue to be risks. KA advised they would continue the improvement of security and resilience of systems across NHS Fife and advised the biggest challenge was in relation to mobile devices and work was ongoing in relation to making home working easier. KA advised Donald Wilson s name would be removed as risk owner for ehealth risks and this would be replaced by Ronald Monaghan. 4.4 Ambulatory Care The Group noted the Ambulatory Care Directorate Risk Report, and MH advised there were no new areas of concern. MH advised Ambulatory Care had addressed a number of risks and a number of successful assessments had now taken place; HSE Inspection to Laboratories; SEPA Visit to Nuclear Medicine; and HAI Inspection to QMH. MH advised within the next six months a reconciliation of the changes in the Directorate management structure in Datix would take place and follow up action take in relation to the CT Imaging Incident. 4.5 Emergency Care The Group noted the Emergency Care Directorate Report, and EC advised Margaret Dodds was now responsible for managing risk within the Directorate. EC advised the majority of incidents were/ 3
were reported from Care of the Elderly, Acute Medical Admissions and Stroke, and themes involving staff were in relation to V&A, staffing, infrastructure and personal accidents. EC advised the key improvements in the Directorate are in relation to the Senior Nurse now responsible for risk management and the Directorate has noticed the improvements made. All major and extreme incidents are escalated to senior management team and executive level in a timely manner. EC advised each speciality is developing their own risk register and bi-monthly risk meetings will be held. 4.6 Medical Director In the absence of a representative to present this report, it was agreed to remit this item to the next meeting. MR 5 DATIX RISK REGISTER PC advised there were currently 35 risks on the Risk Register, with a couple of risk recently amalgamated. Review of 5 Risks: Risk 988: Tissue Viability PC advised JO had reviewed and updated this risk in Datix. Risk 984: Spiritual Care PC advised she had written to JO to ask if this risk could be closed off. JO to prepare a summary of the risk and bring this to the next meeting to enable the Group to consider closing this risk. JO Risk 1300: Spiritual Care PC advised JO had reviewed and updated this risk in Datix. Risk 989: Equipment Failure advised there was now a good system in place to deal with equipment risk and the Equipment Management Group over the past few years had implemented replacements with available funding. to liaise with Jim Leiper to ascertain if this risk can be closed as the risk is low. Risk 1099: Capital Planning advised they have recently rationalised staff available and this risk is low. 6/ 4
6 NEW RISKS Gradient Risk in Corridor Outside Ward 5, VHK The Group discussed the manual handling risks in relation to the gradient risk in the corridor outside Ward 5, VHK, and enquired whether this risk should be added to the Risk Register. Following discussion, agreed to check the position and ascertain if this was an issue. 7 UPDATE ON SCOTTISH PATIENT SAFETY PROGRAMME PC advised: 2 nd phase of SPSP due for release 28-29 August 2013. Sub-Groups set up to look at 4 hand based indicators. NHS Fife is a test site and there would be a small team from HIS visiting Ward 42 in June. Fife Launch of SPSP in Planned Care on 5 June and will be facilitated by Marie Paterson. 8 UPDATE ON INCIDENTS / NEAR MISSES Ward 19, QMH Incident JM advised there had been no update from the Procurator Fiscal or Police. SF advised meetings had taken place to update the Plan. DL enquired how this Plan sat with the Reducing Harm Plan, and PC advised a meeting would take place next week to discuss the Reducing Harm Plan which would be shared through the Clinical Governance Committee. 9 COMPLAINTS There were no complaint issues. 10 TERMS OF REFERENCE PC advised the OD Risk Management Group Terms of Reference was out of date and required to be updated. The Group were asked to consider the current terms of reference and to provide any comments to PC by 4 June. PC advised she would take on board any comments received and would prepare a revised Terms of Reference for the next meeting. PC advised she would also update the template for Directorates to use when completing their Directorate Risk Reports. ALL PC PC 11/ 5
11 LEGAL CLAIMS: Legal Claims 23 May 2013 The Group noted the details and developments of the current Level 3 Claims in excess of 25,000, and noted instructions to our solicitor to negotiate settlement in two claims. The Group noted the details of recent settlements made and JM advised there were now less needle stick injury claims but more fall claims. The Group noted the details of the two negligence settlements and one public liability settlement. 12 ANY OTHER BUSINESS: 12.1 Management of Adverse Events PC advised following the work nationally from the Ayrshire and Arran incident, the HIS visit to NHS Fife in December and the Francis Report, from 3 June 2013, NHS Fife will implement a new Adverse Events Policy as well as new Guidance and Resources for Managing Significant Adverse Events. These will replace the existing NHS Fife Incident Management Policy. PC advised the new Policy and Guidance aims to encourage staff to continue to report adverse events using DatixWeb and information will be made available to staff on the Intranet. PC advised DatixWeb e-mail alerts have been set up to advise key individuals regarding extreme and major incidents. 12.2 Fire Training MH advised as discussed at the OD Health & Safety Committee Meeting, Heads of Department to ensure staff are booking and attending appropriate fire training. MH advised some staff were currently using e-learning but it was noted this was not as a substitute to attending fire lecturers. to ask Iain Kelly to put out a communication to staff. 13 DATE OF NEXT MEETING Thursday 18 July 2013 at 3.00 pm in the Board Room, Hayfield Clinic, Victoria Hospital. GMcK/RiskManagementGroup-Minutes/2013-230513 6 June 2013 6