Report by Mirian Morrison, Clinical Governance Development Manager

Highland NHS Board June 2011 Item 3.7 CLINICAL GOVERNANCE COMMITTEE Report by Mirian Morrison, Clinical Governance Development Manager The Board is asked to: Note that the Clinical Governance Committee met on 17 May 2011 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the consideration of the specific items detailed below. Note the items for discussion at the next meeting to be held on 16 August 2011. Committee Members Present Ms Sarah Wedgwood, Chair Mr Ray Stewart, Non-Executive Director Dr Vivian Shelley, Non-Executive Director Mr Michael Roberts, Lay Member Mrs Margaret Davidson, Non-Executive Director Also Present: Mr Garry Coutts, Chair, NHS Highland (from 11.25 am) Dr Ian Bashford, Medical Director Mrs Liz McClurg, Interim Infection Control Manager Mr Ian Gibson, Non-Executive Director Ms Heidi May, Nurse Director Ms Elaine Mead, Chief Executive (part meeting) Dr Margaret Somerville, Director of Public Health In Attendance: Dr Roderick Harvey, Clinical Director, Raigmore (item 6) Mrs Alex Fraser, Dental Services Development Manager (item 10.3) Mr Bill Reid, Head of ehealth (items 9.4 and 10.2) Mrs Mirian Morrison, Clinical Governance Development Manager Mrs Rachel Hill, Clinical Governance Manager Mr Iain MacDonald, Charge Nurse, Belford Hospital Miss Irene Robertson, Board Committee Administrator Apologies - Mr Quentin Cox and Mr Alan Simmons 1. ITEMS FOR DISCUSSION The items discussed at the meeting are noted below: i. Case Study ii. Rolling Action Plan iii. Antimicrobial Prescribing Pharmacy Post iv. Screening Programmes v. Clinical Governance Committee The Way Forward vi. Significant Incident Reviews in Raigmore Hospital vii. Internal Audit Report on Incident Management System viii. Revised Clinical Governance Strategy ix. Delayed Discharges x. Better Together The Patient Experience xi. Clinical Governance and Risk Management Performance Report

xii. Audit of Decontamination Standards (Dental Services) xiii. Clinical Governance Forum Update xiv. Risk Management Steering Group xv. Information Governance Standards Implementation Plan xvi. Audit of falls related minor injury attendances at A&E xvii. QIS Reviews xviii. NHS Highland Response to the Mid Staffordshire NHS Foundation Trust Reports xix. Nursing Record Keeping Audit 2. ITEMS FOR DISCUSSION AT NEXT MEETING ON 16 August 2011 Emerging Issues Clinical Governance Committee Work Plan Screening Programmes Annual Reports Quality and Patient Safety Strategy ( Clinical Governance) Clinical Risk Register Performance against the Information Governance Standards NHS Highland Response to Mid Staffordshire NHS Foundation Trust Reports Nursing Record Keeping Audit Raigmore Radiology Review Anticoagulation Monitoring Clinical Ethics Committee 3. CONTRIBUTION TO CORPORATE OBJECTIVES This performance report demonstrates how NHS Highland is achieving its corporate objective of ensuring that services delivered are of high quality and clinically effective. 4. GOVERNANCE IMPLICATIONS This performance report has a direct impact on clinical governance and demonstrates performance against responding to complaints, clinical effectiveness activity, patient safety and NHS Quality Improvement Scotland reviews. 5. IMPACT ASSESSMENT This report does not require impact assessment. Mirian Morrison Clinical Governance Development Manager 27 May 2011 2

CLINICAL GOVERNANCE COMMITTEE ASSURANCE REPORT Meeting 17 th May 2011 1. ISSUE: Case Study Issues/Risks Assurance Actions The Committee s role and remit includes receiving reports on any problems that emerge. The Committee requires assurance that action was been taken to address the problems. The committee were circulated with a case study raising a number of issues regarding the care and treatment of a patient. During the discussion a query was raised about how the Board received feedback on complaints and concerns raised by patient receiving treatment out of area. Learning points arising from this case should be shared across the Board Identify how feedback from might be obtained from patients being treated out of area Action Dr Ian Bashford, Board Medical Director 2. ISSUE: Significant Incident Review Process, Raigmore Hospital Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that systems and processes in place to ensure safe and effective patient care The committee were given a presentation on how significant events were investigated within Raigmore Hospital. In particular the committee were given assurance how recommendations were taken forward and how learning was shared across the hospital. There should be consideration if a similar process could be adopted for disciplinary issues Action Raymond Stewart, Non Executive Director It was suggested that a similar process could be considered for disciplinary issues. 3

3. ISSUE: Internal Audit Report Incident Management System Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that systems and processes in place to ensure safe and effective patient care The committee received a detailed action plan which had been prepared in response to the internal audit report. The committee were assured that action was being taken to address the issues in the report. 4. ISSUE: Clinical Governance and Risk Management Performance Issues/Risks Assurance Actions The Committee s role and remit includes providing assurance that clinical governance systems are in place and working The Committee requires assurance that clinical governance systems and process are in place The committee considered the performance report and noted the ongoing work to improve systems for incident and complaints management. Work had commenced to review reports being given to groups and committee across the organisation. This included more analysis especially on outcomes, details of action being taken and sharing of lessons. The committee agreed to have further discussion at its August meeting on how to measure the outcomes of on going work Action: Ms Sarah Wedgwood, Chair, Non Executive Director 4

5. ISSUE: Report on Audit of Decontamination Standards ( Dental Services) Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that systems and processes in place to ensure safe and effective patient care The committee received a detailed report on Highland General Dental Practitioners compliance with decontamination standards. The committee were assured that continued progress was being made with compliance, while recognising that this was based on self reporting. 6. ISSUE: Information Governance Standards Implementation Plan Issues/Risks Assurance Actions The Committee s role and remit includes providing assurance that clinical governance systems are in place and working The Committee requires assurance that clinical governance systems and process are in place The committee received a report on the work that was being taken to achieve compliance against the information governance standards. The committee requested a further report at the next meeting detailing Highland s position, identifying the key gaps. The committee would received a report at its next meeting detailing Highland s position against the information governance standards The committee would receive feedback on the issues and barriers in respect of data sharing at the next meeting. The issue of data sharing was raised and the committee noted the work that had started. Action: Bill Reid, Head of ehealth, Dr Margaret Somerville, Director of Public Health. 5

7. ISSUE: Audit of falls related minor injury attendances at A&E Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that systems and processes in place to ensure safe and effective patient care The committee were informed of the progress that had been made in developing a system for capturing falls related minor injuries at A&E. A report would be prepared on the outcome of this work at the November committee meeting Action: Dr Margaret Somerville, Director of Public Health. 8. ISSUE: NHS Highland Responses to Mid Staffordshire NHS Foundation Trust Reports Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that the operational units have systems and processes in place to ensure safe and effective patient care. The committee received a report summarising the action taken at corporate level and within the operational units to address the recommendation from the Mid Staffordshire reports. The committee agreed to further consider the gaps and concerns at the next meeting Action Mrs Mirian Morrison, Clinical Governance Development Manager It was agreed that further work was required to identify groups and committees taking forward work that would address some of the recommendations to avoid duplication. 6

9.Nursing Record Keeping Audit Issues/Risks Assurance Actions The Committee s role and remit includes interrogating clinical governance systems The Committee requires assurance that systems and processes in place to ensure safe and effective patient care The committee received a copy of the results of the 2010/11 nursing record keeping audit. The results of the audits were managed through the Nursing & Midwifery and AHP (NMAHP) Leadership committee. The committee requested that a report on the outcomes of the various record keeping audits be brought to the next committee meeting. Action: Ms Heidi May, Board Nursing Director The chair wished to see a similar audit of medical record keeping. The committee were interested to see a programme of audits ongoing/planned with Highland. 7

HIGHLAND NHS BOARD DRAFT MINUTE of MEETING of the Clinical Governance Committee Board Room, Assynt House Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/ 17 May 2011-9.15am Present: Also Present: Ms Sarah Wedgwood, Chair Mrs Margaret Davidson, Non-Executive Director Mr Michael Roberts, Lay Member Dr Vivian Shelley, Non-Executive Director Mr Ray Stewart, Non-Executive Director Mr Garry Coutts, Chair, NHS Highland (from 11.25am) Dr Ian Bashford, Medical Director Mr Ian Gibson, Non-Executive Director Mrs Liz McClurg, Interim Infection Control Manager Ms Heidi May, Nurse Director Ms Elaine Mead, Chief Executive Dr Margaret Somerville, Director of Public Health In Attendance: Dr Roderick Harvey, Clinical Director, Raigmore (item 6) Mrs Alex Fraser, Dental Service Development Manager (item 10.3) Mr Bill Reid, Head of ehealth (items 9.4 and 10.2) Mrs Mirian Morrison, Clinical Governance Development Manager Ms Rachel Hill, Clinical Effectiveness and Audit Coordinator Mr Iain MacDonald, Charge Nurse Miss Irene Robertson, Board Committee Administrator 1 WELCOME AND APOLOGIES Welcoming everyone to the meeting, the Chair was pleased to introduce Mr Michael Roberts, one of two newly appointed Lay Members. The second Lay Member, Mr Alan Simmons, was unable to be present. She also welcomed Mr Iain MacDonald, Charge Nurse, who was shadowing Ms Heidi May at today s meeting. Apologies were noted from Mr Quentin Cox and Mr Alan Simmons. 2 DECLARATIONS OF INTEREST There were no declarations of interest made. Mr Ray Stewart outlined his position both as Employee Director and as an employee of NHS Highland. Dr Margaret Somerville reported on the discussion that had taken place at the inaugural meeting of the Clinical Advisory Group on 5 May 2011 in relation to conflicts of interest. The members of the Group had agreed to provide Dr Somerville with a written statement of their interests which would be held on file and updated as required. It was proposed to have some further discussion on this issue at the next meeting. 8

3 CASE STUDY There was circulated for the Committee s consideration an anonymised case study which raised a number of issues from the patient and the patient s family s perspective. The issues identified related more to communication and interaction with staff than to treatment and the impact on the patient s experience during their stay in hospital. Dr Vivian Shelley queried how such incidents and complaints were classified, and highlighted the need to ensure that learning from similar episodes was communicated across the organisation. A query was raised in relation to Highland patients who are treated out of area through Service Level Agreement (SLA) arrangements and how feedback might be obtained on their experiences in order that any issues can be addressed. Noted the issues identified. Agreed the need to ensure that learning points arising from this episode of care were shared across the organisation with the aim of improving the patient experience. Agreed that feedback should be obtained on the experiences of Highland patients treated outwith the area. 4 MINUTE OF MEETING HELD ON 8 FEBRUARY 2011 AND ROLLING ACTION PLAN The Minute of the meeting held on 8 February 2011 was approved subject to the following amendment:- Page 5, item 6.5.1 LSAMO Annual Report, last bullet point, insert OOH on-call before supervisory duties. The rolling action plan circulated with the minute was discussed. It was agreed that timelines would be set for those items noted as reporting to a future meeting. Among those items was a progress report on compliance with the Food, Fluid and Nutritional Care Standards. It was agreed that it would be helpful for the members to have sight of the local reports of NHS QIS review visits, and accordingly the links to these documents would be circulated when they were published. Discussion followed on the Scottish Patient Safety Programme. It was agreed that the Committee s focus should be on monitoring the achievement of intended outcomes in the future and what impact had been achieved in terms of improving patient care and experience. Reports prepared for the Committee should therefore provide assurance that appropriate action has been taken and identify what impact the action has had in improving patient care and experience. In response to a query from Dr Vivian Shelley regarding the Policy for Consent to Treatment, Surgery and Invasive Procedures, Mirian Morrison confirmed that following wide consultation some amendments had been made to the draft document. A working group had been set up to further refine the policy to provide patients with more information and clarity around the consent process. A timescale would be identified for the development of the policy and submission to the Senior Management Team for ratification. The role of the Clinical Governance Committee would be to consider any governance issues in terms of outcomes arising from the introduction of the policy. 9

Approved the Minute subject to the amendment discussed. Agreed that the Chair and the Committee Administrator would review the rolling action plan and establish timelines for each of the actions. Agreed that its focus should be on outcomes and accordingly reports prepared for submission should identify the impact of actions taken and provide assurance of continuous improvement to quality of care and patient safety. 5 MATTERS ARISING 5.1 Antimicrobial Prescribing Pharmacist Post Further to the concern raised at the last meeting in relation to continuing funding for this post, Heidi May was able to confirm that the necessary resource had been identified. The Committee Noted that funding had been identified to enable this post to be continued. 5.2 Screening Programmes Further to previous discussion in relation to the Committee receiving the annual reports of the various steering groups, Dr Margaret Somerville pointed out that some of these were prepared at national level (breast screening, for example) and would not be available until June or July. She therefore proposed to bring the reports to the August meeting of the Committee. The importance was emphasised of establishing links between the steering groups and appropriate managers in order to ensure that recommendations made by the groups were considered and acted upon as necessary. The Committee Agreed to receive the annual reports of the steering groups at its meeting in August 2011. Dr Roderick Harvey joined the meeting 6 CLINICAL GOVERNANCE COMMITTEE THE WAY FORWARD The Chair welcomed Dr Roderick Harvey to the meeting. She referred to the circulated discussion paper she had prepared which set out a number of proposals for the future direction of the Committee in light of the impending review of the Clinical Governance Strategy and the need to reflect the changes in the Committee s role and remit. She explained that to support the discussion a presentation on the DATIX incident reporting system would be given by Dr Harvey and to demonstrate how the information captured by DATIX was used by the organisation in respect of identifying and acting upon serious incidents, and the action plan from the Internal Audit report on incident management systems within NHS Highland would also be considered. DATIX Dr Harvey described the use of the DATIX system to identify and focus on the more serious types of incident occurring within Raigmore Hospital. Significant event review meetings were now held, as required, the reports of which were submitted to the Raigmore Quality and Patient Safety Management Team with recommendations for action. Action plans were produced, with lead officers and timescales allocated to each action, and tracked to ensure implementation. It was felt that this methodology could appropriately be adopted across the 10

organisation. Dr Harvey outlined the key role of the Clinical Governance Facilitators in monitoring new DATIX reports on a daily basis and ensuring the severity of the incidents has been appropriately graded. A query was raised in relation to procedures that carried potential complications and how these could be monitored to identify if any trends were emerging. It was acknowledged that DATIX had limitations and that there was a need for parallel monitoring through the clinical directorates. With regard to learning and consistency of practice some of the events were presented to the monthly divisional audit meetings. Wider sharing of learning across Highland would be achieved through the Clinical Governance Forum. Assurance that recommendations and learning points had been implemented would be obtained through Operational Unit reports and minutes. It was suggested that dealing with events involving staff conduct might helpfully be dealt with through the significant event review process rather than going down the disciplinary route, and could also provide an opportunity for sharing learning points. Mirian Morrison referred to a flow chart a decision tree which she suggested might be discussed with colleagues in Human Resources to consider how it might be integrated into incident reporting. The Chair thanked Dr Harvey for his informative presentation on DATIX and the ongoing work to improve processes and procedures. Noted the introduction of the significant event review process and the mechanisms for ensuring actions were followed up and learning points shared. Recommended that further consideration should be given to the arrangements for grading the severity of events Agreed that the proposal to integrate the decision tree into the incident management system should be explored. Dr Harvey left the meeting Internal Audit Report on Incident Management System Action Plan Mirian Morrison spoke to the circulated action plan developed to address key recommendations highlighted within the Internal Audit Report. A key area for attention was ensuring actions were followed through and the loop closed in order that the organisation could be assured that recommendations made were actually implemented and improvements actually made. Mrs Morrison gave details of the steps taken to date and the further work planned to address this and other issues identified in the report. The Committee Noted the actions taken to address the issues identified in the report and was content to endorse the planned actions would address key recommendations within the report. Revised Clinical Governance Strategy - the way forward There was tabled a draft Quality and Patient Safety Strategy (Clinical Governance) which the Committee considered along with the proposals in the Chair s paper. In the ensuing discussion it was noted that NHS Highland had in place a Strategic Framework and a Quality and Patient Safety Framework, therefore the need for an additional strategy document to reflect the function of the Clinical Governance Committee was questioned. It was suggested that the Clinical Governance Strategy might be integrated into the Quality and Patient Safety Framework, and the Committee s core business could be captured in its role and remit and annual work plan, based on the Framework. Rachel Hill referred to a letter dated 30 March 2011 from the Scottish Government updating Boards on the implementation of the Healthcare Quality Strategy. It had been agreed to establish a set of six quality outcomes 11

and twelve related indicators which define the priorities for healthcare quality improvement across Scotland. The Committee, in developing its remit and work plan, would need to align its focus with these to ensure it was not causing unnecessary duplication of effort. Turning to the Chair s paper, there was general agreement with the proposals, although there were differing views expressed on the suggestion to change the name of the Committee. In order to receive assurance of effective systems in place, the Committee agreed to continue to receive minutes from the Operational Units. In addition, it was suggested that the Executive Directors on the Committee might attend operational unit meetings to get further assurance of governance. With regard to the groups and committees reporting to the Clinical Governance Committee, assurance of governance might perhaps be obtained from them through the submission of annual reports. Further consideration would be given to these suggestions. Agreed that the revised Clinical Governance Strategy would incorporate the Quality and Patient Safety Framework and the revised role and remit would be submitted to the next meeting. Agreed that further consideration would be given to the proposals in the Chair s paper in the light of the points raised during discussion. Garry Coutts joined the meeting 7 EMERGING ISSUES 7.1 Delayed Discharges The Committee considered a letter dated 10 February 2011 which Nicola Sturgeon had sent to NHS Board Chairs in Scotland regarding their arrangements for ensuring that there are no undue delays in discharging patients who are deemed clinically fit to be released from hospital. Elaine Mead confirmed that there was a comprehensive system in place within NHS Highland for identifying the status of each patient and that their position was rigorously monitored. She explained some of the factors that can contribute to delays in patients being discharged back into the community. With the move towards intermediate care the need was emphasised for appropriate mechanisms to be in place to ensure the position continued to be monitored in respect of this group of patients. Was satisfied that there were robust systems in place within NHS Highland to enable the timeous discharge of patients from hospital and that appropriate measures were being taken to minimise undue delays. Agreed that with the move towards intermediate care a mechanism needed to be established to ensure patients with delayed discharge status continued to be monitored. 8 HEALTH, WELLBEING AND CARE 8.1 Better Together The Patient Experience Roll Out of Ward Questionnaires Mirian Morrison updated the Committee on progress, noting that the second round of the Inpatient Patient Survey was due to close next week. The overall response rate in Highland was currently 58%, it was anticipated that the results would be available in August this year. 12

Mrs Morrison advised that a local questionnaire had been developed for use at ward level to enable real time feedback to be obtained from patients to complement the findings of the national survey in relation to their satisfaction with services. This was being introduced in Raigmore and in hospitals in North Highland CHP in the first instance and would be rolled out in due course across the area. Noted progress with the roll out of ward questionnaires. Agreed to consider, at its meeting in November 2011, the findings of the second round of the survey, together with the feedback from ward questionnaires, and the impact of actions taken to address issues identified. 9 ASSURANCE AND ACCOUNTABILITY 9.1 Clinical Governance and Risk Management Performance The Committee considered Mirian Morrison s circulated report which summarised incident activity for the year April 2010 March 2011, gave details of upgrades to the DATIX incident management system to improve its functionality, and set out performance against the 20 day response target for complaints. In this latter regard she referred to the new arrangements for complaints management which came into effect on 1 April 2011. It was too early at this stage to identify the impact of these measures. It was intended to review performance in the next month or so when any improvements in the position should be evident. It was noted that the figures for March 2011 had indicated an improving position against the target. Mrs Morrison outlined the work being done to further refine the content of the regular reports sent to the various groups and committees within the operational units, enabling more detailed analysis of the data to be undertaken which can be used to inform actions to address issues identified. In this connection it was noted that within the inpatient setting the number of slips, trips and falls - which remained in the top five categories of incidents reported - had been reduced in specific areas where detailed scrutiny of the data had enabled targeted action to be taken. Noting that slips, trips and falls remained in the top five categories of incident reports, the Committee considered whether to have an update on falls prevention with more detailed analysis. It needed to be assured that issues had been followed up. It agreed its focus should be on outcomes what was happening at local level, the impact of actions taken. Drilling down into the data revealed that specific types of falls were occurring in specific areas. Action was able to be taken and in the inpatient setting there was now a downward trend. An assurance that issues identified are being addressed should be included in the performance report. In response to a query as to whether it was possible to disaggregate the data in order to identify variations in different settings, Mrs Morrison reported on work that had just begun to run analyses of incidents by category, by site, and by month. The Committee agreed to have further discussion at its August meeting on how to measure the outcomes of the ongoing work. Noted the content of the report. Agreed that further consideration would be given to mechanisms for measuring outcomes of the ongoing work at the next meeting. Alex Fraser joined the meeting 13

The Committee took agenda item 10.3 next 10.3 AUDIT OF DECONTAMINATION STANDARDS (DENTAL SERVICES) The Chair welcomed Mrs Alex Fraser, Dental Service Development Manager, who spoke to her circulated report which provided an update on Highland General Dental Practitioners compliance with decontamination standards. An improvement had been noted in the number of practices achieving compliance, however Mrs Fraser advised that this had been based on self assessment and a survey subsequently carried out by the Board s Head of Decontamination had identified that not all of these practices were fully compliant. The Board s Dental Practice Advisers were working with these practices to help them to achieve compliance. They would also be following up practices who had not yet confirmed their intentions in respect of compliance. A key area of non-compliance was around process and training. It was noted that NES provided relevant training programmes. Mrs Fraser outlined the different timescales for achieving compliance depending on each practice s circumstances. With regard to monitoring compliance with the standards, a decision was awaited as to whether this would be done through NHS Boards, the Practice Inspection Programme, which was currently under review, or Healthcare Improvement Scotland. A concern was raised in relation to potential gaps in service provision due to noncompliance. Mrs Fraser clarified that practices were required to confirm to the Board that they were complying with the current standard level of decontamination of instruments. In addition, practice inspections would identify such issues and any risks would be escalated through the Dental Clinical Governance and Risk Management Group for appropriate action. The Board may refer a practice to the General Dental Council in the event that it did not implement the recommendations and actions arising from a Board inspection, or failed to respond to the need to achieve compliance by the due date. The Committee Noted the update and was assured that continued progress was being made with compliance, while recognising that this was based on self reporting. Mrs Fraser left the meeting The Committee returned to the order of the agenda 9.2 Clinical Governance Forum Update There was circulated the minute of meeting held on 12 January 2011 and the agenda of the meeting held on 3 May 2011. Noting a reference on the agenda to Surgical Profiles 2011, Dr Vivian Shelley enquired whether the response would require to be signed off by the Clinical Governance Committee on behalf of the Board, as was previously the case. Mirian Morrison undertook to confirm if this was still a requirement. The response had to be submitted to Healthcare Improvement Scotland by 20 June 2011. The Committee noted that a review of the Forum s effectiveness would be undertaken at the end of the year. Noted the reports of the meetings held on 12 January and 3 May 2011. Remitted to Mirian Morrison to confirm whether the Board s response to the Surgical Profiles for 2011 required to be signed off by the Clinical Governance Committee. 9.3 Risk Management Steering Group There was circulated for the Committee s information the minute of the meeting held on 17 March 2011. The Chair reported on her discussion with Elaine Mead in relation to how risk 14

management links in to the Clinical Governance Committee and the means whereby assurance can be provided that risks are identified and addressed. It was noted that a clinical risk register was being prepared which would identify risks, lead officers, actions and timelines. It was agreed that the document would be submitted to the next meeting of the Committee. Noted the minute of meeting held on 17 March 2011. Agreed that the clinical risk register which was currently being drawn up would be submitted to the next meeting for consideration. 9.4 Information Governance Bill Reid joined the meeting The Chair welcomed Bill Reid, Head of ehealth, to the meeting. 9.4.1 Information Governance Standards Implementation Plan Mr Reid spoke to his circulated summary paper. He noted the considerable work ongoing around the Implementation Plan to achieve compliance with the Information Governance Standards, and reported developments within the Information Governance Committee in terms of its membership and activity. There had been an improvement in the position regarding feedback from the Centre on NHS Highland submissions. Currently, however, no feedback was being received. Mr Reid suggested this may be due to a reorganisation of the national information governance function. He had taken the opportunity to raise the matter with a representative of the Scottish Government who had attended the recent meeting of the Information Governance Committee and had been given an assurance that feedback would be provided. Thanking Mr Reid for his update, the Chair requested that he prepare a further report for the next meeting detailing NHS Highland s current position against the Information Governance Standards, identifying key risks and gaps. In terms of assurance Mr Reid confirmed there were robust policies and procedures in place to support delivery against the Standards. Information management and governance systems were also subject to regular internal and external audit scrutiny, these reviews serving to identify areas of potential risk. A point was raised in relation to data sharing. The Committee, noting that Mr Reid met on a regular basis with Dr Margaret Somerville in her role as Caldicott Guardian, recommended that they give consideration to achieving integration of work with partner agencies on this particular issue and report back on the outcome of their discussions. There was also an issue around the type of information presented to the Board in terms of quality and governance and where this sat within the risk management framework. It was agreed that Dr Somerville and Mr Reid, together with Mirian Morrison, would take this piece of work forward. Requested that Mr Reid prepare a report for the next meeting setting out the position in relation to NHS Highland s performance against achievement of the Information Governance Standards. It was agreed that the report of the QIS review visit, when Highland had been assessed at Level 2, would be circulated for the members information. Requested that Dr Somerville and Mr Reid further explore the issues and potential barriers identified in relation to data sharing and feed back to the next meeting. 15

Remitted to Dr Somerville, Mrs Morrison and Mr Reid to give consideration to the governance of information provided to the Board and associated risks and report back to the next meeting. 9.4.2 Information Governance Committee There was circulated for the Committee s information the minute of meeting held on 28 February 2011 The Committee Noted the minute. 9.4.3 Audit of falls related minor injury attendances at A&E Following a presentation by Judith Catherwood, Associate Director, AHPs, on falls prevention at its meeting on 9 November 2010, the Committee had recommended that she liaise with ehealth with a view to developing a Highland wide system for identifying falls related minor injury attendances at A&E where the patients presenting had not required hospital admission. Mr Reid reported on the work already being done by the ehealth and Service Planning Teams around reporting and coding of incidents. Dr Somerville noted the work underway within Public Health and proposed that her team pull together a report encompassing the work being done at national level as well as local activity and issues. It was agreed that a report be prepared for the November 2011 meeting of the Committee Noted the work ongoing at local and national level. Agreed that Dr Somerville would arrange for a report to be prepared on the outcome of this work for consideration at the November 2011 meeting. 10 SAFE AND EFFECTIVE CARE Mr Stewart left the meeting 10.1 Update on recent NHS Quality Improvement Scotland (QIS) Reviews As discussed at item 4 it was agreed that when the local reports of review visits were published the Committee Administrator would circulate the appropriate links to the members to enable them to access the documents. It was noted that the local report of the review of the Sexual Health Standards was now available. The reports relating to the Coronary Heart Disease Standards and Endoscopy Services at Caithness General Hospital were awaited. The Committee Noted the publication of the local report of the review of the Sexual Health Standards. The Committee Administrator would circulate the link to the members. 10.2 NHS Highland Response to Mid Staffordshire NHS Foundation Trust Reports There was circulated report by Mirian Morrison summarising the action taken to date in response to the findings of the Healthcare Commission s investigation and the recommendations in the Francis Report. As the reports had identified issues relating to IT and information governance the Chair invited Mr Reid to stay for discussion of this item. 16

Each of the operational units had identified key issues to be addressed in their respective areas and had developed action plans to address them. It was acknowledged that the operational units would have different priorities; however there was a need to ensure a consistency of approach and standards. Some of the actions would be followed up through other routes, for example Infection Control and the Scottish Patient Safety Programme. It was therefore important to ensure clarity around responsibility for key actions to avoid duplication. Mirian Morrison and Rachel Hill undertook to identify roles and responsibilities for the various areas of work. Noted the action plans developed by the operational units to address the findings of the Healthcare Commission s investigation and the recommendations in the Francis Report. Agreed to have further discussion at the next meeting around the gaps and concerns identified and how they are being addressed, and to consider a mechanism by which assurance can be obtained of positive outcomes. Mr Reid left the meeting 10.3 Audit of Decontamination Standards (Dental Services) Discussed earlier in the meeting. 10.4 Nursing Record Keeping Audit There was circulated copy of the results of the 2010/11 general nursing record keeping and care planning audits in NHS Highland. Noting the information, the Chair indicated that she would wish to have an analysis of the findings on the basis of which an action plan should be developed to address any issues identified. She would wish to see a similar exercise undertaken in respect of medical record keeping. Heidi May advised that the nursing audit had been running for several years now and comparable data was available. An AHP record keeping audit programme was also in place. Ms May advised that the outcome of the findings of the Nursing and AHP audits would be managed through the Nursing & Midwifery and AHP (NMAHP) Leadership Committee. On a general point the Committee would be interested to see a programme of the audits ongoing/planned within Highland. The Committee Requested that a report on the outcomes of the various record keeping audits undertaken be prepared for consideration at the next meeting. 11 FOR INFORMATION 11.1 Reports from Operational Units The following minutes were circulated:- Mid Highland CHP Clinical Governance & Risk Management Group draft minute of 2 March 2011 Raigmore Quality and Patient Safety Management Team minute of 16 February 2011 and draft minute of 16 March 2011 South East Highland CHP Clinical Governance & Risk Management draft minute of 23 March 2011 17

As there was insufficient time to discuss the minutes in detail, members were asked to liaise with the Chair outwith the meeting on any issues they wished to pursue. 11.2 Reports from Committees The following minutes were circulated:- Maternity Services Strategy and Coordination Group minute of 16 February 2011 Cancer Steering Group minute of 11 January 2011 Control of Infection Committee minute of 16 February 2011 Area Drug and Therapeutics Committee minute of 19 January 2011 As with the reports from the Operational Units, members would raise any issues identified with the Chair following the meeting. The Committee Noted the minutes and would pursue any issues identified with the Chair following the meeting. 11.3 Clinical Governance Committee Annual Report 2010 2011 There was circulated for the Committee s information and approval copy of its Annual Report for 2010 2011 which would be submitted to the Audit Committee at its meeting on 17 May 2011. The Committee Noted and Approved the content of its annual Report for 2010 2011. 12 DATE OF NEXT MEETING The next meeting will be held on Tuesday 16 August 2011 at 9.15am in the Board Room, Assynt House, Inverness. The meeting concluded at 1.00 pm 18