1 Present: Joint Audit and Quality, Safety & Experience (QSE) Committees Minutes of the Meeting Held on Tuesday 11 th October 2016 in the Boardroom, Optic Centre, St Asaph Mr Ceri Stradling Mrs Margaret Hanson Cllr Cheryl Carlisle (in part) Mr John Cunliffe Ms Jenie Dean Cllr Bobby Feeley (in part) Mrs Lyn Meadows (Joint Chair) (Joint Chair) In Attendance and Observers: Mr Gary Doherty (in part) Mrs Gill Harris (in part) Mrs Grace Lewis-Parry Dr Evan Moore Mrs Vicky Morris Ms Kate Parry Professor Michael Rees Ms Dawn Sharp Mr Adrian Thomas Mr Mark Thornton Mr Chris Wright Chief Executive Executive Director of Nursing & Midwifery Board Secretary Executive Medical Director Director of Quality Assurance Corporate Governance Manager Healthcare Professionals Forum Chair Deputy Board Secretary Interim Director of Therapies & Healthcare Sciences Community Health Council Vice Chair Director of Corporate Services Agenda Item JAQS16/1 Joint Chair s Opening Remarks Action By Mrs M Hanson extended a welcome to all those present. Mr C Stradling indicated it was a requirement of the Audit Committee handbook to work with the Quality Safety & Experience (QSE) Committee, and that in 2015 this had been met through the role of the former Integrated Governance Committee. JAQS16/2 Minutes of Meeting Held on 20.11.14 for Accuracy and Matters Arising JAQS16/2.1 Accuracy The minutes were agreed as an accurate record.
2 JAQS16/2.2 Matters Arising Mrs V Morris added that with regards to the Annual Quality Statement, further substantial assurances had been received on the process through an internal audit report. With regards to deteriorating patients, it was confirmed that the RRAILS audit was undertaken annually, and the matter was within the clinical audit plan and one of the Board s 14 quality and safety priorities. It was noted that clinical coding remained part of the ongoing remit for the QSE Committee. Mrs G Lewis-Parry confirmed that Committee responsibilities would be subject to further review by Mrs A Lloyd (Independent Adviser) in November. JAQS16/3 Arrangements for Reviewing Significant Internal and External Audits JAQS16/3.1 Ms D Sharp presented the paper which had been updated further to discussion at Audit Committee earlier in the year. She reminded members that the Audit Committee were responsible for tracking responses to audit recommendations and confirming that the actions undertaken were sufficient. There had been discussions in terms of the robustness of the process in ensuring the Committee could be properly assured when being asked to confirm actions as closed. The Audit Committee had concluded that the existing tracker tool spreadsheet was not able to provide the required level of assurance and had agreed that for significant audits, the relevant committee would be required to follow up progress and provide an assurance report to the Audit Committee. Ms Sharp outlined the role of the Committee Business Management Group (CBMG) in ensuring appropriate scheduling on Committee agendas. [Cllr B Feeley and Mr G Doherty joined the meeting] JAQS16/3.2 Mr C Stradling also stated that the Audit Committee had the flexibility to require the attendance of an Executive lead for a particular report where there was deemed to be a significant lack of progress or an unreasonable delay in progress. JAQS16/3.3 Mrs M Hanson noted the importance of the triangulation of information from a range of sources and felt there was a need for clarity on the wider programme of work across external regulators. Mrs G Lewis-Parry indicated that there was a level of coordination of plans between Welsh Government, Healthcare Inspectorate Wales, Wales Audit Office (WAO) and internal audit, and that the Audit Committee did receive the respective audit plans from WAO and internal audit. Mr C Stradling suggested that the respective audit plans for the coming year be shared at CBMG. GLP JAQS16/3.4 Mrs G Lewis-Parry referred to the letter from Dr Andrew Goodhall, a copy of which had been provided, and confirmed there was a new requirement for Health Boards to share any low assurance internal audit reports with Welsh Government (WG). Officers were working with internal audit colleagues to agree an appropriate reporting template, with the second return due for submission within the next week. Mr C Stradling outlined his concern that some reports may have to be submitted to WG before they had been discussed at Audit Committee, however, Ms D Sharp confirmed that consideration had been given when planning Committee meeting dates, and that as a minimum the reports
3 would have been circulated to s upon publication. JAQS16/3.5 In response to a question from Mr M Thornton, Mrs G Lewis-Parry confirmed that the level of assurance for internal audit reports was set by internal audit, with the lead Executive having an opportunity to challenge the level and agree a management response at the draft stage. JAQS16/3.6 Mrs G Lewis-Parry also reported upon a fundamental change to governance arrangements in that the Audit Committee would routinely meet in public as from December onwards, in response to a recent Welsh Health Circular. She confirmed that the flexibility to hold an in-committee session would be retained. JAQS16/6 Medical Clinical Engagement in BCUHB [Item taken out of order at Chair s discretion] JAQS16/6.1 Dr E Moore presented the paper. He reported that the results of a Medical Engagement Scale Survey within NHS Wales would be publically shared in due course. He provided his personal views on clinical medical engagement, suggesting it was a measure of how doctors felt about their organisation, how willing they would be to go the extra mile, and a measure of how valued and involved they felt. Dr Moore stated that the paper set out a range of actions to be taken forward including clarification of medical staffing structures, addressing issues around job planning, increasing the visibility of leadership and improving decision making processes. JAQS16/6.2 Prof M Rees reported that he had been directly involved in aspects of improving clinical engagement for several months and whilst there was significant enthusiasm, ideas and goodwill amongst clinicians, there were some barriers to making improvements. He suggested there needed to be more cross-discussion between clinicians and managers, more sharing of skills, flexibility to allow clinicians to undertake additional development work, and improvements to systems to ensure they were equitable and transparent. [Mrs G Harris joined the meeting. Cllr C Carlisle left the meeting] JAQS16/6.3 Ms J Dean made the point that medical engagement should not be separated out completely from the wider BCUHB staff engagement strategy. Mr M Thornton referred to discussions at a recent QSE Committee workshop with the Quality Assurance Executive, and felt that clinical engagement did need to be a priority for the Health Board. He also felt that an absolute measure of how well organisations were doing on engagement was lacking across Wales. JAQS16/6.4 Mrs M Hanson referred to the associated communications action plan and enquired as to the accountability for monitoring. Mrs G Lewis-Parry confirmed that the Strategy, Planning & Population Health (SPPH) Committee had overall responsibility for engagement, however the detail of the individual action plan would be owned by the Executive lead. The QSE Committee would require a broader level of assurance that medical engagement was being addressed and improvements made, from the perspective of its impact on patient experience. Mrs L Meadows as Chair of SPPH would ensure the Committee was sighted on the matter, and also link in with Mr Martin Jones as part of the wider BCU engagement strategy. LM
4 JAQS16/6.5 Mrs G Harris felt there were opportunities for the clinical executives to work together to identify good practice and principles of clinical engagement that would be transferrable across other disciplines eg medical, nursing and therapies. JAQS16/4 Medical Equipment Good Practice JAQS16/4.1 Mr Patrick Hill (North Wales Medical Physics Department) was in attendance to deliver a presentation which detailed:- The scope for medical devices, covering all aspects of healthcare The EBME (electro biomedical engineering) sector within BCUHB The SUM approach (suitable, understood, maintained) A description of the medical devices governance and committee structures within BCUHB and the importance of multi-disciplinary approach Recommendations of the WAO report Learning from the WAO report, areas of good practice Process for incidents via Datix Examples of recent incidents Added value from the process Next steps and how the Board could help JAQS16/4.2 Ms J Dean noted that one of the benefits of an asset register was to enable the organisation to have an accurate picture of the equipment available to it and to give assurances that the equipment was appropriately calibrated or to flag when it was coming to the end of its useful life. She expressed a concern that there may not be a sufficiently resourced replacement programme to address this and recalled that in previous years, departments had utilised charitable funds for equipment replacement. Prof M Rees also suggested that replacement needed to be in a more planned and proactive way, rather than a short turnaround response to funding when it was released by WG. JAQS16/4.3 Mrs G Lewis-Parry reminded members that the WAO report on medical equipment commended the Health Board for learning from when things go wrong, and suggested that the Committees try to identify areas of best practice that could be replicated elsewhere. Mrs G Harris felt that scrutiny within the area teams was key, and clear methodologies to underpin decision making. Mrs V Morris suggested that ensuring ownership, particularly around training, was important. Mr G Doherty felt that there were some characteristics that could be replicated for example the allocation of a guaranteed budget however there were additional complexities with revenue than capital. Mr M Thornton suggested that a common culture and understanding of an approach should be strived towards. JAQS16/4.4 Mrs M Hanson thanked Mr P Hill for his attendance and the presentation. She confirmed that the Audit Committee had received the full WAO report, and that the QSE Committee should consider how to read across learning and processes into other areas. MH GH JAQS16/5 Clinical Audit JAQS16/5.1 Mr A Thomas delivered a presentation which incorporated:
5 Definitions of and differences between audit and research ie research is concerned with discovering the right thing to do, and audit ensuring it is done right. The benefits and outcomes that Clinical Audit provides. The Clinical Audit Cycle. Process for prioritising audits within BCUHB. The role of the National Clinical Audit and Outcome Review Advisory Committee and the associated tiers for audit. The WG assurance proformas (copies tabled) Topics for Tier 2 audits within BCUHB and statistics for Tier 3 Additional support and activity provided through Clinical Audit Detail of the Clinical Audit team within BCUHB JAQS16/5.2 Mr A Thomas tabled a briefing paper on the BCUHB 2016/17 Clinical Audit Plan which incorporated the NHS Wales National Clinical Audit & Outcome Review Programme and the Health Board Corporate Clinical Audit priorities. JAQS16/5.3 Mrs G Harris reported that she and Mr Thomas had had conversations regarding the alignment of the audit and improvement programmes, and the need to prioritise in alignment with the organisational improvement programme. Prof M Rees felt that there should be prioritisation of audits that were productive, and that research should be encouraged alongside audit. Ms M Hanson felt that clinical audit should be used to improve an improvement journey, and there was a need to link in with the Quality Assurance Executive. JAQS16/5.4 In response to a point raised by Mr C Stradling regarding information flows and the role of QSE Committee in terms of reporting lines, Mr A Thomas outlined timing issues relating to the release of the national clinical audit programme, and accepted that the scheduling of clinical audit work into the QSE cycle of business could be improved. Mrs G Lewis-Parry reminded members that the audit plan should focus on the key priorities of the organisation. Mrs G Harris suggested that key lessons learned and red RAG ratings from various audits needed to be reported up to QAE but the overall plan would continue to be signed off by the Audit Committee. JAQS16/5.5 It was agreed that Mrs G Harris and Dr E Moore would further consider how sharing of learning and scaling this up at pace could be achieved. In addition, Mr A Thomas would look to utilise the Tier 3 proforma for other tiers. GH EM AT JAQS16/7 Issues of Significance to Inform the Chair s Assurance Report To be agreed with Chair and submitted to next available Health Board meeting. It was also agreed that the minutes of the joint meeting be submitted to the QSE and Audit Committees for noting and ensuring follow up of actions. KP JAQS16/8 Date of Next Meeting To be convened for autumn 2017. KP