LOTHIAN NHS BOARD PAPER 17 HEALTHCARE GOVERNANCE & RISK MANAGEMENT COMMITTEE Minutes of the Meeting of the Healthcare Governance and Risk Management Committee held at 9.00am on Tuesday 17 th April 2007 in the Board Room, Deaconess House, 148 Pleasance, Edinburgh. Present: Mr S Smith (in the Chair); Dr C P Swainson; Mr R Y Anderson; Dr A McCallum; Mr E Egan; Ms P Dawson; Ms R Strachan; Ms T Douglas; Dr M Winter; Ms S Gibbs; Mr J McCaffery; Ms H Tierney-Moore; Dr B Montgomery; Dr J Jenkins; Mr M Mehdi; Mr D Forbes; Ms S Lloyd; Ms J Stirton; Ms V Baker; Mrs M Anderson; Ms S Lee In Attendance: Dr C Kalman; Mr C Graham Apologies for absence were received from Mrs P Murray; Cllr I Whyte; Mr R Burley; Dr I Mckay; Ms L Campbell; Mr D Bolton; Mr J Forrest 107. Minutes of Previous Meeting 107.1 The minutes of the meetings of 20 February 2007 were accepted as a correct record of the meeting subject to the following amendments:- Page 3, third paragraph under 95.4, last line should read SNOMED not SNOWMED Page 8, third line should read UNICEF not UNIFEC Page 10, final paragraph re hip fracture performance needs to be reworded Page 15, third paragraph should read children s nursing and not children nurseries The Committee also noted that in future the Information Meeting minutes/action note would be submitted to the formal committee meetings for approval. 108. Matters Arising 108.1 Update on Clinical Coding (Item 95.4 from 20/02/07 minute) The Committee were informed that the six week target for discharge summary coding is currently around 60%, there were still remaining issues. There was a local backlog which was being reduced through the use of an action plan and there was a merge team addressing coding. The backlog was reducing slowly however the information was highly accurate. It was suggested that more action on wards may be required with nurses/clerical staff coding themselves. Bed statements may also be reinstated. Use of the TrakHealth system may also be made mandatory. It was also hoped that there would be a single discharge summary revised data template for documentation of discharge. There were concerns expressed about the potential for additional workload being placed onto Nurses by non-nursing duties. The Committee noted that
as yet there had been no proposals submitted to the partnership forum or divisional management team. It was reported that there was still teams of Clinical Coders and that they had not been disbanded. There were currently 3 teams of Coders, at the Western General Hospital, the Royal Edinburgh Hospital and St John s Hospital in Livingston. However the mechanisms used by each team were varied. It was hoped to encourage accurate local data entry. The Committee noted that there was no agreement with nurses to do this and that staff cannot be forced to do it. Committee members were informed that as an organisation it was important to know where patients are and why they are there. There needs to be agreement at ward level for this. Accountability for this is with the Director of Finance. The Committee agreed that the processes of the transition to electronic records need to be looked at again and that a written report should go to the Audit Committee, Finance and Performance Review Committee and to the next meeting of this Committee. HTM/VB 109. Other Minutes 109.1 Minutes of the Primary Care Organisation Clinical Governance Operational Group held on Thursday 18 th January 2007 The Minutes were noted. There was discussion on the new CHPs/CHCPs terms of reference. The Committee felt that it was important that the meeting agendas for each CHP followed a template which could be shared consistently across Lothian including topics such as child protection, adult protection, complaints analysis and trends (quarterly), critical incidents and trends (serious ad hoc, otherwise quarterly), review of risk register (CHP/CHCP one at each meeting), effective clinical care, NHS QIS reviews and action plans, monitoring of clinical governance strategy & clinical effectiveness plans and quality assurance. The Committee were informed that there is currently a paper with the CHP subcommittee looking at standardising guidelines and agendas. It was also pointed out that representation from each CHP was expected at all future Healthcare Governance and Risk Management Committee meetings. There was discussion on the Quality Assessment Visits. The Committee were reassured that key risk issues for NHS Lothian were being identified and addressed, specifically the issue of vaccine fridges. At present it was felt that this issue was being addressed and a recall was not required. It was reported that in Lothian there has always been a good return of vaccine logging and there had been two incidents over the past year where out of date vaccines had been given. One incident was actually a transcription error. 2
The Committee noted that current practice is more than meets the requirements under the SEHD paper and agreed that a paper expanding on this should come to the next meeting. AKM The Committee also agreed the CHP General Managers would be written to regarding standardisation of agendas. CPS The Committee also discussed the issues around diary pressure of CHP representatives, how CHPs could be better supported and how statutory subcommittees could best be approached. There were also concerns raised about the importance of health and safety in the CHPs, this was especially concerning as it was likely that there would be a Health and Safety Executive (HSE) review of NHS Lothian shortly. The Committee were informed that the Edinburgh CHP would be looking at risk management and managing health and safety at their next half away day. The Committee agreed that this issue should be taken back to the Partnership Forum. EE 109.2 Minutes of the University Hospitals Division Clinical Governance & Risk Management Committee held on Friday 9th February 2007 The Minutes were noted. The Committee acknowledged the continuing rollout of the HELICS method in critical care and also the cleaning schedules in particular for curtain changing. It was also noted that these Committee meetings were being used to pull out problems which remain on the agenda until they are dealt with. There was discussion around end of life care and appropriate support. The Committee noted that support from the palliative care team was not always asked for. 109.3 Minutes of the Health & Safety Committee held on Thursday 11 th January 2007 The Minutes of the Committee s second meeting were noted. The importance of attendance at the health and safety meetings was emphasised. There was discussion on incidents of violence and aggression, the Committee noted concerns that although there was a zero tolerance approach to violence and aggression towards staff, staff still felt threatened by it. There were also concerns expressed about the lack of staff training in the management of aggression. It was noted that there were also concerns coming from staff trainers at the number of courses that were having to be cancelled due to lack of numbers attending sessions. It was suggested that perhaps better use of bank and agency staff was required to avoid staff missing training. There was discussion on the potential of e-learning which 3
was currently being used, as a short term interim policy until the end of 2008, to provide manual handling training. The Committee felt that the protocols for the training budget may need to be looked at to establish how best to use the funding. There was discussion on recording of incidents. It was agreed that a one streamlined reporting system would be useful and the Committee asked if it would be possible to establish why incidents took place or a top 10 list of incidents and hotspot areas. The Committee also suggested that it may be worthwhile looking into training on a larger scale (scotland wide) perhaps in conjunction with other health boards and the SEHD. JTM 110. Workplan 110.1 Revised Terms of Reference The Committee noted the changes to the terms of reference to include attendance of representatives from CHPs and CHCPs. It was noted that Information Governance had been omitted and that this should be added in under the functions of the committee section. CPS 110.2 Committee Annual Report to the Board The Committee noted this end of term report to the parent Board. The report has been drawn from the Committee minutes for the previous year. Expansion of Risk Management was required and showing learning from complaints may be useful. It was noted that this report was to go to the May Board meeting and that any changes or improvements should be emailed directly to the Medical Director by the 11 th May 2007. CPS 111. Clinical Effectiveness 111.1 Occupational Health Annual Clinical Governance Plan & Report The Chairman welcomed Dr C Kalman to the meeting. The Committee were informed that before 2005 there was no clinical governance occupational health in NHS Lothian and that physiotherapy was now recognised by the Health and Safety Executive (HSE). The current service is under resourced and there is no physiotherapy currently at St John s Hospital. The Committee noted that the proposed service would be run on a spend to save basis with every pound spent return one to six pounds back. It was also stated that the agreed actions for the 2005-2006 programme were now complete. 4
There were concerns raised about attendance at work and the time spent waiting for occupational health referrals. It was noted that this would hopefully reduce once a single system was established but ultimately delays came back to resource issues. The Committee noted that there was funding agreed for one staff grade starting from June 2007. The amount of funding secured for the programme for 2007-2008 was 250k. With the funding secured it was hoped to enhance nurse referring and run a four year programme instead of the initially proposed three years. It was suggested that a NHS Lothian risk register be developed and it was agreed that the spend to save financial model was correct. There was discussion on the Monitoring of Complaints and Review of Critical Incidents (Section 8 of the report) The Committee found this an interesting area but it was unclear who would take this forward and monitor it. The Committee were reminded that the NHS Lothian occupational health service chose not to be aligned with fife or Lanarkshire but does provide some services to other health boards and the Scottish Executive. There was discussion on workplace assessments and staff counseling services The Committee suggested that Dr Kalman should submit future reports to the Finance and Performance Review Committee with clear recommendations and emphasising the spend to save approach. It was agreed that a copy of this section of the minute be forwarded to the Chair of Finance and Performance Review Committee and the Director of Finance. CG 111.2 Health & Inequality Update The report updating the Committee on actions taken to address health inequalities in the past year was noted. There was discussion about the effectiveness of health impact assessments and quality improvement. The Committee noted that the impact assessments had been used to pick up changes for 1 year now and that a random sample of questions asked had been viewed. Concerns were then raised over child protection in the traveling communities and the difficulties with processing and keeping of records. Concerns were also expressed about current child dietician waiting times and GP child referrals to Weight Watchers. The Committee noted that the childhood obesity framework would be going to the Board in May or July. There was also discussion about risk management for staff working with traveling communities. The Committee asked for an additional column to be added to the report for recording of evidence based outcomes and clear evidence of money equaling results. Also it was noted that there was no mention of deaf/hard of hearing in the action plan. AKM 5
111.3 Clinical Documentation Group - Final draft action plan The Committee were informed that this was still to be seen as a work in progress as the Clinical Documentation Group had not met since the last meeting of this Committee. The Committee agreed that this should come back to the Committee when finalised. BM 112. Quality Assurance 112.1 Progress Towards Staff Governance Standard The Committee noted that the report showed very well the progress being made in Lothian. It was also noted that NHS Lothian was the only board in Scotland where the Partnership Forum has the Board s authority to approve employment policies. There was discussion on staff personal development plans (PDPs) The current level of staff with PDPs is around 70% The Committee were informed that currently there was no agreed general policy on alcohol testing of staff. However some staff were taking up alcohol counselling as an alternative to disciplinary action. The policy on MHRA was nearly agreed. The Committee discussed sickness, absence and staff morale. It was noted that an independent survey or examination of sickness/absence would be useful. The Committee agreed that this should be taken to the Staff Governance Committee (SGC). EE 112.2 Update on Radiation Protection Committee The Committee noted that the Radiation Protection Committee was now up and running it has met three times and continues to operate satisfactorily. It was noted that there was concern about the continuing absence of an RSAC certificate holder at the Royal Hospital for Sick Children (RHSC). This was a breach of statutory requirement but there was an action plan in place. However an inspection would pick this up as non statutory compliance. 112.3 Cervical Screening Programme Annual Report The Committee found the report self explanatory and it was noted. 6
112.4 NHS Boards' Overall Strategy for Preparedness and Response to Pandemic Influenza Report The Committee discussed the report. There were concerns over the preparedness and staff training. The Committee asked for a formal response to the training issues. JTM 113. Risk Management 113.1 Clinical Governance Register The Committee noted that there were several incomplete items in the report and asked that these items were addressed by the responsible Directors. AKM/JM 113.2 Healthcare Associated Infection (HAIs) The Committee noted the report. There was discussion about recent presentations on decontamination of endoscopy and dental instruments. The Committee discussed how communication and risk assessment could be improved. The Committee were concerned that this topic was again back at the table. The Committee needs to see evidence of things being done, actions taken and improvements implemented. AKM was requested to submit an action plan to the next HG&RM Committee. AKM There was further discussion on the process with the decontamination group and the non-compliance situation in NHS dentistry. The Committee were informed that HAIs would be discussed at the nonexecutive board members education session scheduled for 25 th April 2007. The session would be looking at what HAIs are, the key issues for Lothian and how they are being addressed. THE CHAIRMAN LEFT THE MEETING AT THIS POINT. MR E EGAN AGREED TO CHAIR THE REST OF THE MEETING. 7
113.3 Update of Jarvie Report The Report was noted. The Committee expressed appreciation to Ann Jarvie for her input to the report. The Committee were informed that the Liberton incident was now complete. A person sensitive approach to care was now being developed. There was discussion about the potential for a non-executive director to take on a older peoples champion role. Chair to raise this with non-executives. SHS The Committee were informed that at a recent Protection Of Vulnerable Adults (POVA) Training session there had been a poor turnout from staff that would have probably benefited most from the training. 113.4 Clinical Governance with Scottish Ambulance Service The Committee agreed to defer this paper to a future meeting. 113.5 Quarterly Report of Critical Incidents and Trends The Committee noted the reports showing incident statistics from July September 2006 and October to December 2006. The Committee were advised that the statistics were currently being compiled using two incident reporting systems, SAFECODE and DATIX. There was discussion on the reports, the incident reporting schedule and template (appendix 3), the not stated incidents and their follow up and how better completion of forms could be encouraged. The Committee were also informed of the recent Health Department Letter (HDL)(2007)13, which deals with prevention of falls in older people. The Committee would like to see incidents of HAIs and medication related incidents being included in the report. The Committee also asked for a report on the recent work done and whether this fits in with the recent HDL. SG 113.6 Analysis of Litigation and Claims The report was noted. The Committee discussed the timescale for settling on non clinical claims and there was discussion on the legal standing of negligence in relation to MHRA claims. The Committee noted that the claim levels in England were much greater than in Scotland. 113.7 Child Protection - Joint Inspection of Child Protection Arrangements The Committee noted the Action Plans. 8
The Committee were informed that there was now updated version of the East Lothian Action Plan and both the Midlothian Action Plans. These updated Action Plans would be circulated via email for comments. HTM The Committee noted that the Inspectorate for Midlothian having asked for the Action Plan seemed now not to want it. It was noted that a number of areas in the Midlothian Action Plan required rewriting and a number of costs needs to be quantified. The Committee were informed that currently there was no enough child protection advisers in place and only 5 had been appointed. There was discussion on information for children on the Children Charter information for practitioners on children s rights. The Committee felt that it was important that GPs were being engaged. There was discussion about nursing in the community and how health visitors in certain parts of Lothian were under more pressure than others. Perception of risk was also mentioned. It was felt that a consistent approach to risk assessing according to health was needed. CHP and pharmacist responsibility in identifying risk was also raised. 114. Items for Information 114.1 Update on dates for Business Continuity and Training Meetings It was noted that this would be an item for discussion at the Board Away Day on 25 th April 2007 114.2 The Scottish Patient Safety Alliance The Committee agreed to defer this paper to a future meeting. 114.3 Maternity Services Liaison Committee Annual Report 06/07 The Annual Report was noted. 114.4 Education for Scotland Themes and Issues 2004-2006 The circulated document was noted. 115. Any Other Competent Business 115.1 Topics of Future Information Meetings The Committee were informed of the suggested core topics for future information meetings, these were Child Protection, NHS QIS Reviews, Business Continuity and Health & Safety Reports. The Committee also agreed not to cancel the July Information Meeting. Other topics to be covered at future meetings included patient safety alliance, modernising medical careers and inequalities in health. The Committee also suggested talks on finance, other aspects of child health community paediatrics, how CHPs hosting services pan Lothian carry out Risk Governance and the Clinical Governance and Risk Management of the transfer of patients from the State 9
Hospital to NHS Lothian. The Committee noted that there would be a suggested plan for 2008 meetings outlined at the November 2007 information meeting. PD 116. Date of Next Meetings Tuesday 15 th May 2007 from 9.00 to 16.15 Full Day Quality Improvement conference at Our Dynamic Earth Tuesday 19 th June 2007, 9.30am, Board Room, Deaconess House 10