Working with you to make Highland the healthy place to be

Assynt House Beechwood Park Inverness IV2 3HG Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/ MINUTE of MEETING of the CLINICAL GOVERNANCE COMMITTEE Board Room, Assynt House Tuesday 15 February 2005-2.30pm Present Also Present Joy Fraser, Chair, Non-Executive Director Heather Sheerin, Non-Executive Director and Chair of DHS Committee Alison Graham, Medical Director Nigel Hobson, Associate Nurse Director Ken Oates, Acting Director of Public Health and Health Policy Roger Gibbins, Chief Executive, NHS Highland In Attendance Iain M acritchie, H ospitals C haplain (for item 4) Mirian Morrison, Clinical Risk and Services Manager Lesley Anne Smith, Clinical Risk Manager Irene Robertson, Board Committee Administrator Apologies - David Alston, Margaret Davidson, Bill McKerrow, Peter Mutton 1 MINUTES The minute of meeting held on 19/10/04 was approved. 2 MATTERS ARISING 2.1 Future Arrangements for the Clinical Governance Committee The Chairman reminded the Committee that, when it last met on 19/10/04, no dates were set for future meetings pending the outcome of discussions on the proposed new healthcare governance structure. T oday s m eeting w as unscheduled, and the C hairm an anticipated that the Committee would need to continue to meet until the new governance arrangements were established. 3 CLINICAL GOVERNANCE PRINCIPLES 3.1 Publication and Promotion of the Clinical Governance Principles within the Organisation A leaflet had now been printed setting out the six Clinical Governance Principles. It was proposed to launch the P rinciples at the second C elebrating B est P ractice in H ighland C onference on 10/03/05. The Committee recommended that a presentation on the Principles should be made to the DHS Committee, and that a programme should be drawn up to present and promote the Principles within the Community Health Partnerships and the Specialist Services Unit. Working with you to make Highland the healthy place to be

The Committee: agreed that a presentation should be made to the DHS Committee on the Clinical Governance Principles; remitted to Mirian Morrison to make the necessary arrangements for the dissemination of the Principles within the Community Health Partnerships and the Specialist Services Unit. 3.2 Application of the Clinical Governance Principles (a) Sampling Visit to the RNI Community Hospital 17/12/04 The Chairman gave a brief report of the Non-E xecutives visit to the R N I C om m unity H ospital on 17/12/04, the Non-Executives had also had a follow up meeting with the Clinical Governance Team and Managers. Mirian Morrison confirmed that she and her colleagues would be reporting back to the RNI Clinical Governance Team on the main areas covered during the visit, the outcome of the evaluation, and the issues that had emerged from the visit. In general there had been a positive response to the visit. While acknowledging that the visit had been somewhat process driven, the Committee recognised that it was important that the sampling visits should have a focus and needed to take place within an agreed and understood framework. Discussion followed on how the lessons learned from the visit could be applied to other services. The Committee: agreed that further consideration required to be given to the mechanisms for sharing examples of best practice; recommended that reports of visits and action plans should be a standing item on the DHS C om m ittee s agenda. (b) Application of Clinical Governance Principles to Managed Clinical Networks (MCNs) Dr Alison Graham reported on a meeting with MCN Managers and Clinical Leads to discuss options on how to integrate MCNs into the day to day work of NHS Highland and ensure the application of clinical governance. She would let the Committee know when further meetings had been scheduled and how the members might contribute to the discussions. 4 GOVERNANCE OF SPIRITUAL CARE T he C hairm an w as pleased to w elcom e the R ev D r Iain M acritchie, H ospitals C haplain. Nigel Hobson spoke to a paper he had tabled about the establishment of a Spiritual Care Committee and where it might sit within the organisation in terms of governance. A structure had been proposed, modelled on the NHS Tayside system, in which the Spiritual Care Committee would report to the Clinical Governance Committee. Dr Macritchie confirmed that the paper had been considered by the Highland Healthcare Chaplaincy Committee who had endorsed the proposed structure. The Chaplaincy Committee acknowledged that it had a heritage within the Health Service and recognised all the good work done under its auspices. It also recognised the considerable change in faith group representation. The constitution of the new committee would need to reflect the broader nature of spiritual care, while taking cognisance of the local culture. It was proposed to hold a meeting of the Chaplaincy Committee on 26/05/05 with a view to having the first meeting of the Spiritual Care Committee on that date, provided the proposals for its establishment had been agreed. Mr Hobson was arranging for nominations to the new committee to be sought from various groups. On the matter of governance, it was envisaged that the new committee would feed into the DHS Committee. However, until the DHS structure was fully bedded in, it was recommended that the Spiritual Care Committee should report to the Clinical Governance Committee. 2

The Committee requested that Mr Hobson keep its members informed of developments. 5 HEALTHCARE GOVERNANCE INTEGRATION PROJECT Dr Alison Graham gave a presentation on the Healthcare Governance Integration Project which had been established to review the services and structures which supported Healthcare Governance within the organisation with the aim of moving towards an integrated structure and single system working. She referred to the NHS Quality Improvement Scotland Clinical Governance Framework (discussed later in the meeting at item 6.5c) and to a new HDL which was expected shortly, noting that the proposed governance structure would require to take cognisance of both documents. The Project Team had held a number of workshops to consider different structures for integrating clinical governance functions, the draft model now before the Committee had emerged from these discussions. The Project Team proposed the establishment of two posts - a single Head of Clinical Governance and a Deputy Head of Clinical Governance, it felt this option would support the activity and delivery of clinical governance as it would provide clear lines of accountability and integrate existing teams. In the ensuing discussion of the proposed structure, the following points were raised:- There was a distinction to be made between managing the process and providing assurance of systems in place, for which the DHS Committee would be responsible, and looking at the outcom es w hich w ould be the C linical G overnance C om m ittee s role w ith the Non-Executives acting as guardians of the Clinical Governance Principles. Consideration would need to be given to the mechanisms for providing assurance that appropriate systems were in place and working effectively. Where would Public Health, which was an integral part of healthcare governance, sit in the proposed structure? It was felt that the governance of Spiritual Care should lie ultimately with the DHS Committee, but that it w ould rem ain on the C linical G overnance C om m ittee s agenda until the new structure was in place. Clarification was required on the roles and responsibilities of the different committees detailed in the model. What support mechanisms would need to be in place to enable the CHPs and the SSU to undertake their roles in terms of healthcare governance? The Committee: agreed that it would continue to meet on a quarterly basis until the new structure was in place when it would review its role and the frequency of its meetings; agreed that draft roles and remits should be prepared for the various committees detailed in the model, the committee structure to be reviewed in the light of experience; agreed to refer the issues raised to the Corporate Team for further consideration and to provide a detailed overview of the proposed organisational structure; noted that some specific work required to be done around the mechanisms for providing assurance of governance. 3

6 DHS CLINICAL GOVERNANCE AGENDA 6.1 Infection Control - HAI The Committee noted the Annual Report for 2003/2004 of the Highland Acute Hospitals Control of Infection Committee which detailed the work of the committee during that year and set out recommendations for further work in 2004/2005. A work programme had been developed, progress against which was being monitored, and a report would be produced in due course. The Committee noted the issues arising from the report and progress made on implementing the action plan developed to address these issues. NHS Quality Improvement Scotland (QIS) had undertaken a further review of HAI. The Committee noted that a national overview report would be published in May 2005, and NHS Highland would receive individual reports in respect to primary and acute care issues. 6.2 OOH Standards The OOH Standards which NHS Highland was piloting required providers of OOH services to have a system in place to report regularly to the Clinical Governance Committee. Direct Health Services was monitoring the new arrangements which were introduced on 01/12/04, and regular reports were being submitted to the Board and the Corporate Team providing assurance that the new service was operating effectively and that any problem areas were identified and addressed. The Committee agreed to await the NHS QIS report on the pilot and would formalise the reporting arrangements once the standards were published. 6.3 Risk Management T he C om m ittee received Lesley A nne S m ith s report of a w orkshop for senior m anagers held on 15/12/04. A further workshop would be arranged for CHP colleagues who had been unable to attend the first event. Dr Smith explained that action plans had to be developed for high level risks. The legacy risk registers from the three arms of the old organisation ensured that much of this work had already been done. In addition, a Risk Management Steering Group was to be established which would monitor progress against the action plans. The Committee recognised the need to roll out the risk management process to all levels of the organisation. 6.4 GMS Contract Quality and Outcomes Framework T he P atient s experience form ed part of the G M S Q uality and O utcom es F ram ew ork. G P Practices were now required to undertake patient surveys and discuss the results with either a patient group or Non-Executive members of the Primary Care Organisation (Highland NHS Board). A number of Practices had requested the involvement of Non-Executives in this process. Accordingly arrangements would be made to notify Non-Executives about this initiative and invite them to participate. 6.5 NHS Quality Improvement Scotland (QIS) (a) Review Visits - Monitoring of Implementation Plans i. NHS QIS Standards for Healthcare Associated Infection (HAI Infection Control) This had been discussed at item 6.1 above. 4

(b) Forthcoming Review Visits The Committee noted the schedule of review visits, as follows:- Pilot Out of Hours 03/03/05 (discussed at item 6.2 above) Learning Disabilities 27 28/04/05 Food, Fluid and Nutritional Care week commencing 17/10/05 The review of the Management of Post-mortem Examinations took place at the end of 2004 and the report was due to be launched in the week commencing 21/02/05. The final report for NHS Highland had been received and an action plan developed to address the unmet standards. Areas requiring improvement included the formal documentation process and audit. Areas of good practice, such as the involvement of the Chaplaincy in providing spiritual care and support to adults and children, would be highlighted in the national report. The final draft report on Anaesthesia Standards had been received and was currently being analysed. (c) NHS QIS Clinical Governance Framework This consultation document set out the Framework for how NHS QIS proposed to support the implementation of clinical governance across NHSScotland. Comments were invited on the document for submission to NHS QIS by 28/02/05. Dr Oates commended the Framework, but suggested that it should also reflect the health improving role of Health Boards, for example, in respect to reducing inequalities and fair access to services. NHS QIS had also issued the final report of its Clinical Governance Scoping Exercise, the aim of which had been to gain an overview of the structures in place and identify specific training and support requirements for clinical governance staff. The Committee remitted to Dr Graham to draft a reply on its behalf to the consultation paper, incorporating the above comments and the points made during discussion of the Healthcare Governance Integration Project (item 5 above). 6.6 Clinical Effectiveness Strategy Work was ongoing towards achieving a single, integrated system. The Chairman would wish the Committee to receive a progress report in due course. The Committee noted this topic for discussion at a future meeting. 6.7 Performance Assessment Framework (PAF) The Committee agreed to have an update on progress against the PAF criteria at its next meeting. 7 CRITICAL REVIEW OF RECRUITMENT OF LOCUM MEDICAL STAFF Dr Graham outlined the interim arrangements that had been put in place pending the report of the Working Group which was due to present its final recommendations to Highland NHS Board at its meeting on 05/04/05. The Committee noted the position and would await the outcome of the report. 5

8 CLINICAL GOVERNANCE COMMITTEE ANNUAL REPORT The Committee was required to produce an annual report of its activities in order that the Statement of Internal Control could be signed off. The members discussed the content of the report and agreed that it should include a summary of progress with the Healthcare Governance Integration Project. It was suggested that future reports could be based around the Clinical Governance Principles and the activities undertaken in each of these areas. The Committee: remitted to Dr Graham, Mrs Morrison and Dr Smith to prepare a draft report; agreed that the report should be submitted to the Audit Committee at its next meeting on 22/03/05 and thereafter to Highland NHS Board at its meeting on 05/04/05. 9 CLINICAL ETHICS COMMITTEE As Brian Devlin was unable to be present, the Committee agreed to receive his report on the establishment of the Clinical Ethics Committee at its next meeting. 10 ANY OTHER COMPETENT BUSINESS 10.1 NOSCAN Clinical Governance Policy A copy of the N orth of S cotland C ancer N etw ork (N O S C A N ) s C linical G overnance P olicy w as tabled for the C om m ittee s consideration in term s of its application to other clinical netw orks and interaction with local systems. NOSCAN saw its role in respect of clinical governance as supplementing traditional clinical governance. The means by which it sought to fulfil that responsibility were summarised in paragraph 6 of the policy document. Recalling previous discussion on this policy at its meeting on 19/10/04, the Committee agreed that the standards as detailed in paragraph 6 of the policy were acceptable. The issue was about how NHS Highland engaged with bodies such as NOSCAN and ensured that the Clinical Governance Principles were being applied. Dr Graham proposed to raise this issue at the next meeting of the local Cancer Steering Group at which the manager of NOSCAN would be present. She would also ask the Cancer Steering Group to consider the policy document and convey any comments back to NOSCAN. The Committee agreed the course of action proposed by Dr Graham. 11 FUTURE GOVERNANCE ARRANGEMENTS AND DATES OF FUTURE MEETINGS In the light of the discussion on governance arrangements at item 5 above, the Committee agreed that it would continue to meet during 2005. The next meeting would be held on Tuesday 26 April 2005 at 2.00pm. S ubject to confirm ation of m em bers availability, the follow ing dates w ere proposed for the remainder of the year:- Tuesday 19 July 2005 at 2.00pm Tuesday 18 October 2005 at 2.00pm 6