a public benefit corporation

a public benefit corporation BOARD OF DIRECTORS Minutes of the meeting of the corporation s board of directors on Wednesday 30 July 2008 at 1.00 pm in the board room, Royal Hospital Present: In attendance: Apologies: Mr R Gregory, Chairman (in the chair) Mrs J Birkin, Non Executive Director Mr P Briddock, Executive Director - Finance and Contracting Mr R Clarke, Executive Director - Nursing Mr M R Hall, Non Executive Director Mr J McDonnell, Executive Medical Director Mrs P Liversidge, Non Executive Director Mr E J Morton, Chief Executive Mr D Whitney, Non Executive Director Mr J A Jones, Corporate Director - Allied Clinical and Facilities Services Mrs N Tucker, Corporate Director - Planning and Performance Mrs S Turner-Saint, Head of Communications Mrs E Watts, Executive Assistant to the Chief Executive (minutes) Mr T J Alty, Executive Director - Corporate Secretary Ms D Fern, Non Executive Director ACTION BD122/08 Attendance of the corporate directors It was noted that Mrs Tucker, Mr Jones and Mrs Turner-Saint were in attendance in an advisory capacity. BD123/08 Declaration of interests The following changes to the register were noted Mr Gregory to remove - Non Executive Director Business in the Community Ltd Mr Briddock - to add - appointed visiting teaching fellow at Sheffield Hallam University Board of Directors Page 1 of 12

Mrs Liversidge to add - Guardian of the Assay Office in Sheffield The other executive and non-executive directors present at the meeting had no additional interests to declare. The board received the declaration of interests pursuant to section 6 of Standing Orders. BD124/08 Minutes of the meeting held on 25 June 2008 The board received and approved the board of directors minutes held on 25 June 2008. BD125/08 Action from the minutes BD110/08 chairman s items additional board of directors time-out Mr Gregory advised that a convenient date for an additional time-out was proving difficult. He added that this is essential, but needs full board attendance to review board effectiveness and asked Mrs Watts to canvass diaries for dates early in the New Year. EW BD110/08 chairman s items FTN two day conference Mr Gregory explained that to date the corporation had no representatives available to attend this two day conference. He had suggested Jeanette Harding, Anna Pridmore s replacement attends. He added that if any non executive director was interested and available to attend to let Mrs Watts know. BD110/08 chairman s items - Health Select Committee Mr Gregory provided a brief update on the evidence he gave to the Health Select Committee on 3 July. The transcript was available if anyone wished to see it. BD113/08 risk committee Mr Gregory informed the board that Jeanette Harding, currently head of internal audit had been appointed as head of compliance. She would take up her post in October. BD126/08 Matters arising from the minutes There were no matters arising from the minutes. BD127/08 Chairman s items Council of governors The chairman provided a verbal update on the Council of Governors meeting held on 2 July 2008. A number of items were highlighted in particular the presentation by Derbyshire County PCT. The governors received a presentation from representatives of Derbyshire County PCT on the Our NHS, our future vision for Derbyshire. The representatives John Raine, chair, Derek Bray, chief executive and Martin Whittle, director of strategy highlighted key recommendations from the vision document. Board of Directors Page 2 of 12

The PCT had agreed to the corporation s community members being consulted on their vision. A questionnaire on key areas of development and change would be circulated to the members with a covering note from John Raine. The results from the consultation would be discussed at a special council of governors meeting on 22 October. Mr Gregory advised that non executive directors would be invited to attend this meeting. The minutes from the meeting would be presented to the board at the September board meeting. BD128/08 Report of the chief executive Mr Morton presented the report of the chief executive. The following items were highlighted: New name for children s unit Mr Morton confirmed that The Den had been chosen for the new name for the children s unit. Mr Jones and Mrs Turner-Saint had hosted the cheque presentation to the winning school. C difficile update Mr Morton referred members to appendix 1 of the report. He reiterated the point that the measures that were agreed at the last board meeting on 25 June would be kept under review to ensure they remained appropriate but would be changed if necessary. He added that following a review of the proposal to introduce disposable curtains, it had been agreed to suspend this proposal. The significant resource earmarked for their introduction would be better utilised to provide additional support staffing to wards over the holiday period. The board agreed that it was important that measures were kept under constant review and diverted if necessary. Mr Morton handed over to Mr Clarke and Mr McDonnell to update the board on the details of the additional measures that had been introduced and included on the action plan. Introduction of revised antibiotic prescribing policy - Mr McDonnell advised that the antibiotic prescribing policy had now been amended. He added that ongoing monitoring of antibiotic prescribing patterns and C diff rates would inform any further changes in the policy that may be required. This was a move in the right direction. The board noted that the C diff currently in the hospital was the new more resistant strain of infection known as 027. Mr Clarke circulated the report from James Paget University Hospitals that highlighted their experience of dealing with rising levels of C diff and an outbreak of 027 strain. Mr Gregory updated the board on a meeting that had taken place with Derbyshire County PCT to discuss infection control. The trust confirmed the work on antibiotic prescribing which was already in place. It was agreed that the pharmacists now in post would be asked to review to ensure primary care was consistent with the approach now in place. The PCT agreed it would communicate the revised guidance to GPs and community pharmacists via the PCT medical director. The PCT also agreed to communicate that the C diff currently was the 027 strain and that all GPs should use the revised guidance in the treatment of C diff. Board of Directors Page 3 of 12

It was agreed that a comprehensive health community communication strategy on infection control and in particular on C diff was required. Part of the communication plan should include a hand washing strategy and that urgent work on changing the culture of hand washing was required. The overall communication strategy should be jointly signed by both chairmen with medical director endorsement to reinforce the importance on this by both organisations. In terms of drafting the communication strategy, recognising the subsequent sensitivities surrounding this issue, it was felt that the trust should draft up the text for approval with the PCT. Mr Clarke would liaise with Mrs Turner-Saint to take this forward. RC/STS Root cause analysis for each new case Mr Clarke confirmed that from November 2007 the trust had in place a systematic review process (RCA) for all patients whose death certificate mentioned C diff. This process has now been extended for all new cases of C diff. Department of health contacted for advice Mr Clarke reported that the DoH advisor on control of infection has been contacted and recommended that the trust use the SHA local control of infection advisor. A visit has subsequently been arranged for 6 August 2008. The Health Protection Agency had met with senior staff within the trust. HPA were unable to give any additional advice on any further action that could be undertaken but did agree to do more typing of the C diff strain. The trust was now typing all new cases. Introduction of hand washing audits Mr Clarke advised that a process of daily ward audit of compliance with hand washing has been introduced. The early results showed variable compliance. It was noted that failure of compliance was challenged at the time of the audit. Mrs Birkin raised her concerns regarding hand washing and felt that some form of training should be introduced. A general discussion took place. Whilst changes to the antibiotic prescribing policy and C diff policy were welcomed, board members expressed concerns about the continuing hand washing issues. Recent audits showed that clearer guidance about when to wash hands or not, and when to wear gloves or not, was required. The board recognised that this confusion could have been generated by so much information that had been circulated to staff and that clarity had been lost. As a result the board members agreed that as part of its overall infection control strategy mandatory training for all staff that have direct patient contracts should be introduced. Board members discussed ways of delivering this training. It was agreed that the training would best take place in the workplace and would consist of hand hygiene instruction. It was further agreed that anyone attending would complete a sign-off form that would go on their personal files. It was hoped that the entire trust would undergo the training over a two to three month period. Board of Directors Page 4 of 12

Mr Clarke commented on the matron s event that was taking place on 31 July. Mr Gregory and Mr Morton agreed to attend this event acknowledging that this would be a good opportunity to launch this approach. This would also reinforce the board s commitment to this training. Mr Jones provided an update on the use of portable sinks at ward entrances. Mr Gregory asked for signs to be installed on every gel dispenser alerting to the fact that gel does not combat C diff and urging users to wash their hands as well. Post meeting note: Following the board meeting the Strategic Nursing and Professional Advisory Group members have received training in brief intervention hand hygiene training. In addition the matron event with a total of 60 senior nursing staff also received training on the five key moments of hand hygiene. A pack will be available at the next board meeting for information. Plans are now in place to roll training out across the trust with a weekly report on numbers to the director of nursing. High Impact interventions (HII s) HII s have been issued to all bed holding areas, the medical directorate were completing these for all new C diff cases. Surgery were now developing a programme for introduction. Results would be reported in future clinical standards and governance reports. Hydrogen peroxide cleaning Mr Jones provided an update advising that an evaluation of the systems on the market for using hydrogen peroxide have been undertaken and the trust have purchased machines for use by our domestic team. The system is operated in a screened off area and uses programmed machines to dispense the chemical which sticks to surfaces and acts as a disinfecting agent. The machine is safe to use on all manner of equipment including beds, commodes and electrical equipment. Purchase of additional analyser approval has been given to purchase an additional analyser machine now on order. This enables the existing methodology to be continued and allows for two or three C diff runs per day. In addition to speeding up C diff results reporting, it also provides backup for the main analyser. Surgical cohort area in response to a run of C diff cases on surgical wards and difficulty in isolating other symptomatic but not C diff positive cases, a surgical cohort area of 13 beds was established on Staveley ward on 18 July to address the problem. The temporary arrangement was suspended as soon as the surgical situation was under appropriate control. Mr Clarke provided an update on the C diff cases reported in ITU and the subsequent actions taken. Board members discussed the trust s figures to date which were reporting 26 over trajectory. It was acknowledged that there had been no MRSA cases reported for June. Board of Directors Page 5 of 12

The board noted the work undertaken so far and the additional measures that had been put in place. These would be kept under constant review. Healthcare associated infection (HCAI) inspection programme 2008/09 Board members noted that the corporation had been selected by the Healthcare Commission (HCC) for an inspection against the code of practice for the prevention and control of healthcare associated infections. The visit would take place between 1 August and 31 October 2008. Mr Clarke advised that 70 pieces of documentary information had been collated and sent to the Healthcare Commission in preparation for the visit. Safer Chesterfield Board Mr Morton advised that Mr Jones would be the corporation s representative on this group. Visit by North East Derbyshire District Council Mr Morton commented on the visit by North East Derbyshire District Council representatives on 8 July. He added that the council were interested in pitching one of our partner governor seats at the next round of governor elections. East Midlands weekly performance report The members received the report for information. The board received the chief executive s report and noted the contents. BD129/08 Clinical governance committee Mr Whitney presented the minutes of the clinical governance committee held on 16 July. A number of items were highlighted and discussed. The board received the minutes. BD130/08 Clinical standards and governance report Mr Clarke and Mr McDonnell jointly presented the clinical standards and governance report for April to June 2008. The board s attention was drawn to the following: Dr Foster real time monitoring benchmarking data on the Dr Foster system had now been updated. Performance was now compared with national data for 07/08 rather than 06/07. Alerts Stroke a review of all of deaths during January - March 08 found that in 16 of the 44 cases reviewed there was no conclusive evidence of the patient having had a stroke. As a result an action plan has been developed to improve the accuracy of coding and the care of stroke patients. This would continue to be monitored. Clinical quality indicators obstetrics and maternity caesarean section rates Mr McDonnell advised that the national target was for a 15% caesarean section rate. This target was a challenging aspiration; a rate of less than 20% was seen as being very positive. Board of Directors Page 6 of 12

Booking of emergency cases for theatre report details an audit undertaken by Dr Ian Gell, clinical director in critical care. Overall the audit showed poor compliance with the policy for booking of emergency cases for theatre. As a result the policy would be re-launched via clinical management team and then re-audited. Geneva hand hygiene project this project utilised fluorescent powder, only visible under UV light, to highlight the importance of hand hygiene and cleanliness in the reduction of the spread of infection. Mr Jones advised that random audits by domestic services would be taking place using this methodology. The corporation would then be undertaking both visual and microbiological audits. It was acknowledged that this was a useful piece of work that may help to understand some of the underlying causes that have contributed to ineffective hand hygiene and cleaning processes. It was confirmed that a re-audit would take place in six months time. Overview of antibiotic use and prescribing initiatives 2007/08 this report highlighted the work undertaken by pharmacy to control the use of antibiotics as part of the measures to control C diff. As a result of this work, the report highlighted significant reductions in the inappropriate prescribing of antibiotics. Investigation outbreaks of C diff at Maidstone and Tunbridge Wells NHS Trust action plan showed that only seven of the original 24 action points were now left to complete. RC Learning beyond registration (LBR) this was a useful piece of work that illustrates the quantity and diversity of LBR education planned for 2008/09. The report also showed how the training reflects and supports the development and deliver of trust services. Audit of inpatient parkinson s disease medication June 2008 a good piece of work which highlighted the importance of patients with parkinson s disease receiving their medication on time. Mr Clarke advised that in future the report would be presented in two volumes. Volume one would cover the clinical indicators which the board members would receive at board meetings. Volume two would contain qualitative data such as PPI, clinical audit and education activity. This would be circulated separately to the non executive directors. With regard to volume two, Mr Clarke explained that he would be happy to answer any questions or queries via email. Mr Briddock made reference to a number of inaccuracies to the table on page 44. Mr Briddock agreed to pick up these with Mr Clarke outside the meeting. The board received the report. Board of Directors Page 7 of 12

BD131/08 Annual report on infection control Mr Clarke presented this item advising that the report had been brought forward for board approval prior to the visit by the Healthcare Commission. He drew the board s attention to an error on page 2 the reduction in the number of hospital acquired C diff infection figure reads 54% should be 57%. The board members noted this amendment. Mr Clarke summarised key areas of the report. Mr Gregory acknowledged that the report only covered the period April 2007 to March 2008 and that the significant work done since March 2008 would be included in next years annual report, he felt however that it was important that reference to the last four months actions was incorporated within this report. He added that the board was fully committed to reducing hospital acquired infections and that this was a top priority issue. He added that board members had taken leadership, ownership and appropriate action and this needed to be reflected upon in this report. After further discussion it was agreed to expand paragraph 1.2 of the executive summary to reflect upon the last four months actions. Mr Briddock agreed to forward capital costs to Mr Clarke to include within the infection control business case section. Subject to the above additions, board members approved the 2007/08 annual report and the infection prevention and control programme for 2008/09. BD132/08 Risk committee Mr Gregory presented the minutes of the risk committee held on 25 June. He referred members to the principles paper and the ongoing work being undertaken to develop this document further. He acknowledged that this piece of work was more complicated than anticipated. He summarised the work in progress for the committee looking at ways to achieve a better consolidation between the clinical and non clinical registers. The board received the minutes of the risk committee held on 25 June 2008. BD133/08 Report of the corporate director of planning and performance Mrs Tucker presented the performance management report for the period to 30 June 2008. She advised that the Healthcare Commission had updated their website to reflect the indicators they were currently proposing to use to assess the performance of acute and specialist trusts in 08/09. The changes were different to those originally detailed and were divided between existing commitments and national priority indicators. Mrs Tucker explained the coloured coded text. The board s attention was drawn to the following: Board of Directors Page 8 of 12

Healthcare Commission standards - existing commitment indicators overall performance was good with eight out of nine standards already being achieved. One standard thrombolysis 60 minute call to needle time - was on plan to be achieved. Healthcare Commission standards national priority indicators overall performances showed that six standards were already being achieved and a further four were on plan to be achieved. One standard c difficile - was off plan and one standard indicator on stroke care - was of concern. Mrs Tucker explained that the 18 week referral-to-treatment target would now be measured by specialty not across the trust as a whole. She added that this would be difficult for some specialties to achieve. Indicator on stroke care Mrs Tucker referred members to page 22 of the report drawing particular attention to the review that had been undertaken to establish the reasons why 10 out of 47 patients discharged with a primary diagnosis of stroke during April and May 08 did not spend at least 50% of their hospital stay on a stroke unit. The reasons for non admission to a stroke unit were discussed. Mrs Tucker explained that there were issues around end of care pathway and the need to review criteria for being admitted. She would pick up this issue with the medical directorate to address. 2008/09 Milestones performance for the period was good with four standards out of 43 already being achieved and 36 standards on plan to be achieved. Three standards were off plan elective inpatient waiting times, outpatient waiting times, diagnostic waiting times. Assessment against Monitor s compliance framework based on performance after three months of the year, it was reasonable to assume that all but one of the service performance targets included within Monitor s compliance framework for 2008/09 would be achieved by year end. It was acknowledged that the C diff target remained a significant challenge and there was now some doubt as to whether this would be achieved at year end. On this basis the board agreed to submit an amber return for service performance at the end of Q1. The board noted that if the target for each quarter end was not being achieved by the time of the Q3 submission, it would automatically become red. It was also possible that if the annual target was exceeded before or at the Q2 submission the trust would be rated a red from that time onwards. The board received the report and noted the performance. BD134/08 Report of the executive director of finance and contracting Mr Briddock presented the finance and activity monitoring report for the period to 30 June 2008. The board s attention was drawn to the following: The financial risk rating to date of 4.7 was slightly below plan. It was still anticipated that the forecast 2008/09 risk rating of 4.8 would be achieved. Board of Directors Page 9 of 12

Income and expenditure showed a surplus of 1,768k compared to a planned surplus of 2,199k being an adverse variance of 431k. There were some pressure points in several directorates which were being investigated further to determine the underlying causes and agree recovery plans as necessary. Mr Briddock provided an update on the directorates giving cause for concern: Surgery ongoing discussions indicate that activity levels should improve as the year progresses. Detailed work was continuing to understand the reasons for the nursing overspend. Orthopaedics and emergency care detailed discussions have taken place. The under recovery of activity and income in orthopaedics together with the nursing pay overspends in both areas, was the main focus of attention. Medicine based on deterioration in both income and expenditure positions in June, the general manager has been requested to provide more detail on the reasons for the overspend on both medical and nursing staff. Discussions with the relevant directorates would continue in order to agree recovery plans as necessary. The board noted that funding of the C diff action plan had been factored in to the overall forecast. This significantly reduces the level of contingency reserves available to offset adverse directorate positions. Cash balance was 21.7m which was marginally below the plan of 21.8m. NHS capital expenditure amounts to 2,698K to 30 June compared to a planned position of 4,630. This was mainly due to slippage on the onsite re-provision of children s services. Pay budgets were overspent by 423k, predominately on nursing. With regard to agency staff, Mr Clarke summarised the discussions with NHS Professionals looking at temporary staff solutions. A further meeting to take forward a more formal approach and pursue further has been arranged. In conclusion the board noted that the overall performance for the three month period reinforced the need to maintain tight control on the cost base relative to activity fluctuations. The board also noted that the agreed priority to fund the C diff action plan significantly reduced the level of contingencies available to mitigate against adverse directorate performance. The board received the report and noted the contents. Board of Directors Page 10 of 12

BD135/08 Q1 return and self certification to Monitor Mr Briddock presented this item advising that the Q1 return and self certification needed to be submitted to Monitor on 31 July 2008. A number of minor amendments were noted. The board in particular discussed the declaration. Members felt that it was important to demonstrate that the trust s commitment to reducing hospital acquired infections was a high priority issue on the agenda. It was therefore agreed that the information provided within the declaration needed to be expanded to detail the actions taken so far, incorporating all relevant supporting documentation. Mr Clarke agreed to address this and forward to Mr Briddock for submission to Monitor. RC Subject to the amendments discussed, the board approved the Q1 return and self certification to Monitor. BD136/08 Audit committee Mr Hall presented the minutes of the audit committee held on 2 July 2008 and drew attention to the following items: Removal expenses issue now resolved. It was confirmed that this would not set a precedent. Fraud matters issue related to the compound indicators. Mr Hall and Mr Briddock summarised the background to the issue advising that it was expected that the trust would achieve a 1 rating again, and the only way to increase the rating was to increase the number of days counter fraud was employed within the trust. Audit committee had discussed this issue and investigated how the additional time would be used if more time was added to the plan. The committee concluded that the number of days should not be increased at this stage. A paper outlining what the additional time would be used for would be presented to the audit committee at a later date. Board members noted this position. The board received the minutes. BD137/08 Dates of meetings in 2009 The board noted the dates of the board of directors meetings in 2009. Mr Gregory advised board members to let Mrs Watts have any comments on the dates but asked members to be as flexible as possible with diary availability. ALL BD138/08 Date and time of next meeting The members noted the date and time of the next meeting Tuesday 26 August 2008 Board meeting 9.30 11.30 am board room, Chesterfield Royal Hospital special meeting to discuss the staff survey results Board of Directors Page 11 of 12

Next full board meeting: Wednesday 24 September 2008 Board meeting 10.00 am 1.00 pm board room, Chesterfield Royal Hospital Joint board and council meeting: 1.30 pm 4.00 pm: Lecture room A & B, education centre, Chesterfield Royal Hospital Annual general meeting: 6.30 pm 8.30 pm (open from 5.30 pm for governors to meet with members of the public): The Winding Wheel, Chesterfield BD139/08 Any other business Equitable Access PCT walk in centre in A&E In response to a question from Mr Whitney, Mr Morton provided background information to this issue. He advised that the PCT had chosen to issue a tender specification which bears no likeness to the discussions that had taken place and was impossible for any bidder to deliver to. Mr Morton summarised the specification and added that on this basis the trust had withdrawn from this particular tender. Board of Directors Page 12 of 12