Borders NHS Board Clinical Governance Minutes of a meeting of the Borders NHS Board s Clinical Governance Committee held at 2.30 pm. on Wednesday 8 th September 2010 in the Boardroom, Newstead Present Mr Adrian Lucas (Chair) Mr Vince Summers Mrs Erica Nisbet Mrs Anne Palmer (Shadowing Erica Nisbet) Dr Tom Cripps Dr Ross Cameron Dr Alan Mordue Mr Calum Campbell Mrs Sheena Wright Mrs Alison McHutchison (Minutes) In Attendance (Item 1) : Ms Yvonne Bronsky, Local Supervising Authority Midwifery Officer 1 Apologies: Mrs Catherine Duthie, Mrs Helen Clinkscale 2 Presentation : Local Supervising Authority Midwifery Ms Yvonne Bronksy attended the meeting to update on the South East Scotland Local Supervising Authority annual report to the Nursing and Midwifery Council. She explained that statutory supervision of midwives is integral to midwifery practice and the South East of Scotland supervision is a fundamental part of the financial governance systems within each of the Health Boards Fife, Forth Valley, Lothian and Borders. The report highlights the main points of activity undertaken during the practice year 1 st April 2009 to 31 st March 2010. The NMC was established under the Nursing and Midwifery Order 2001, as the body responsible for the practice of professional midwives for the core functions of education, training, conduct and performance and to ensure these standards are maintained. The Local Supervising Authority (LSA) is the body responsible in statute for the general supervision of midwives practising within its boundaries. Ms Yvonne Bronksy assured the Clinical Governance Committee that at the moment there are no significant issues to address within NHS Borders. Mr Adrian Lucas remarked on this well monitored and excellent regulated service. 3 Minutes of Previous Meeting held on 14 th July 2010 The minutes of the last meeting on 14 th July were noted and approved. Action Tracker All matters on the action tracker have either been completed or will be discussed under matters arising. 1
4 Matters Arising - Monitoring High Risk Patients with Multiple A&E Admissions Mrs Erica Nisbet discussed the monitoring of high risk patients with multiple Accident and Emergency (A&E) admissions. Currently alerts can be added to the A&E Patient Management System prompting clinicians to check the patient s medical notes prior to discharge. Mr Calum Campbell suggested that the Board Clinical Governance Committee take control of monitoring this alert system, restrict the number of alerts issued and categorise by priority group any new alerts. It was agreed that the PMS Project Lead would be asked to submit any change to any alert submissions through the Clinical Governance Committee. - CGC Self Assessment Performance Mr Adrian Lucas suggested that this self-assessment performance monitoring form be issued for comment and further discussion in time for the next Clinical Governance Committee. It was also agreed that a list of the annual reports routinely submitted to the Clinical Governance Committee be added to the proforma. Mrs Erica Nisbet agreed to take this forward. - Surgical Profiles Dr Tom Cripps updated on surgical profiles published by ISD and any issues arising from this report. He explained that the concerns highlighted appeared to be attributable to statistical variation rather than bad practice. He confirmed that these figures will be monitored regularly and this matter has been addressed appropriately. It was agreed that Dr Tom Cripps would provide a written report to the Board Clinical Governance Committee. 5 Priorities - HEI Inspection Mrs Sheena Wright updated on progress against the actions arising from both visits which are now complete and within timeframes outlined. An HEI scorecard has been developed and this will be presented to the HEI Task and Improvement Group at their next meeting. She updated that the Local Inspection Teams are now expanding into the Community. The Chief Inspector and Regional Inspector have recently visited NHS Borders and received good feedback. - Action Plan for NQIS Clinical Governance and Risk Management Standards Review Report Mrs Erica Nisbet updated on this action plan and the progress to date. The Committee discussed this action plan in detail and in particular emergency planning and business continuity requirements. Mrs Erica Nisbet informed the Committee that a proposal to radically review the content of these standards is being considered by NHSQIS. She confirmed that Mrs Jan Warner, Director of Patient Safety and Performance Assessment at NQIS would be attending the November Board Clinical Governance Committee. - Child Protection Health Action Plan Mrs Sheena Wright gave a presentation on the NHS Borders Child Protection Review. She commented that in April 2010 an audit was commissioned by NHS Borders to identify strengths in the child protection process, to identify gaps in current provision and any areas for improvements. This audit was completed in May 2010 and highlighted that staff welcomed the opportunity to participate in this audit and there was a clear commitment to improving services. She discussed that this action plan identifies outcomes, deliverables and lead responsibilities to address the 2
recommendations. Mr Adrian Lucas agreed to ask the Audit Committee to include Child Protection in the future Audit Plan. - Mid Staffs Action Plan Mrs Sheena Wright tabled the draft NHS Borders response to the Mid Staffordshire Inquiry and discussed this action plan. She confirmed that this action plan will also feed into the Quality Strategy. She remarked that a lead person is identified for each work stream and it is now their responsibility to complete the actions within agreed timescales. She updated that this action plan will now be consulted through the Board Executive Team. - Determination FAI Mrs Sheena Wright updated on the recent Fatal Accident Inquiries (FAIs) involving the drug Enoxaparin although each FAI was dealt with separately by the Sheriff. She discussed the determinations received from both cases and updated on the recommendations arising from the outcome of these FAIs. Dr Tom Cripps and Dr Ross Cameron stressed the need for good medical practice and the requirement for all recommendations to be put in place. Mr Calum Campbell updated on his discussions with the Central Legal Office (CLO). 6 Specific Items - Updated Clinical Governance Terms of Reference (for approval) The Board Clinical Governance Committee agreed to approve these Terms of Reference with minor changes in light of Dr Kevin Woods s letter received recently referring to governance standards. Mrs Erica Nisbet agreed to take this forward. - Medical Appraisal Report Dr Ross Cameron updated on this medical appraisal report that has now become an accepted part of professional governance for doctors and has been widely introduced across both primary and secondary care in recent years. He stated that it should be noted that considerable resources have been invested in GP appraisal over the past 7 years, in contrast with the hospital sector where appraisal has been incorporated within existing management structures with little or no extra resources. He stated a new enhanced appraisal system is due to be implemented shortly. 7 Standing Items - Clinical Governance Steering Group (unapproved 15th July) The Board Clinical Governance Committee noted these unapproved minutes. - Clinical Risk Management Group (10 th June, 8 th July, 12 th August) The Board Clinical Governance Committee noted these minutes. Mrs Sheena Wright asked it be noted that if any apologies are received for this meeting a deputy should attend. Dr Ross Cameron raised the issue of closing the loop relating to NPSA/RRR alerts and the requirement for a fail-safe system. It was confirmed that this matter has also been discussed at the NHSQIS Liaison Coordinators meeting and a national process is in development. - Public Health Report Dr Alan Mordue discussed the public health report (HEAT4) to achieve agreed number of screenings using the setting appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines y 2010/11. He updated that this report is to brief the Board Clinical Governance Committee on the Alcohol Brief Intervention target which required remedial actions to meet current targets and to update members of progress. 3
- Scottish Patient Safety Programme Mrs Sheena Wright updated on progress with each of the work streams relating to the Patient Safety initiative. 8 Systems Update - Complaints Report Mrs Erica Nisbet discussed the quarter 1 report from April 2010 to June 2010. The Board Clinical Governance Committee commented on the excellent progress in dealing with the complaints received. Mrs Sheena Wright commented that the ISD report is due shortly. Mr Adrian Lucas discussed the themes around these complaints and the need for these to be investigated further. Mrs Sheena Wright confirmed that this is an objective for the Complaints Officer. - Clinical Risk Annual Report Mrs Erica Nisbet updated on the Clinical Risk Annual Report, the purpose of which is to inform the Clinical Risk Management Group (CRMG) and the Clinical Governance Committee of the CRM activity that has taken place within NHS Borders over the period April 2009 to March 2010. The Board Clinical Governance noted this report. 9 Items for Noting - Clinical Governance Work Programme The Board Clinical Governance Committee noted this work programme. Mrs Erica Nisbet confirmed that this programme will be updated in time for the next meeting. - Clinical Governance Support Team Update Mrs Erica Nisbet updated on work in progress within the Clinical Governance Support Team. - External Review Programme Mrs Erica Nisbet updated on progress with the external review programme. She also discussed the local outcomes of the Clinical Governance and Risk Management standards. - Public Governance Committee Update Mr Adrian Lucas updated that as the Public Involvement and Communications Team now produce a quarterly report and the next report will cover July to September 2010. This will be available for the November meeting. MINUTES - Adult Protection Committee Minutes dated 3 rd August 2010 The minutes of this meeting were noted and approved. - Child Protection Committee Minutes 10 th June 2010 The minutes of this meeting were noted and approved. - Other Papers HDLs etc. There were no additional papers to note. 10 Any Other Business 4
Mr Calum Campbell and Dr Ross Campbell confirmed that the Penrose Inquiry Report is due to be issued on 9 th September 2010. Mr Vince Summers intimated that he will no longer be representing the Area Clinical Forum (ACF) on the Board Clinical Governance Committee as he will be resigning as Chair of this Forum on 31 st October 2010. 11 Date of Next Meeting The next Board Clinical Governance Committee will take place on Wednesday 10th November 2010 at 2.00 pm. in the Boardroom at Newstead 5