ST ROQUE BOARD ROOM, ASTLEY AINSLIE HOSPITAL

PAPER 5.1 NHS LOTHIAN HEALTHCARE GOVERNANCE AND RISK MANAGEMENT COMMITTEE DRAFT v2 MINUTES OF MEETING of PRIMARY AND COMMUNITY SERVICES HEALTHCARE GOVERNANCE and RISK MANAGEMENT OPERATIONAL GROUP DATE: THURSDAY 6 DECEMBER 2007 VENUE: PRESENT: APOLOGIES: ST ROQUE BOARD ROOM, ASTLEY AINSLIE HOSPITAL Pat Dawson, Associate Nurse Director, NHS Lothian Sue Gibbs, Clinical Governance Manager, NHS Lothian Lorna Martin, Chief Nurse, REAS (Minutes 1 5.2) Ian Johnston, Clinical Director, East Lothian CHP Sandra McNaughton, Deputy Dir. of Pharmacy, NHS Lothian Duncan Miller, General Manager, PCCO Tom Murphy, Clinical Director, REAS (Minutes 4.1 11) Joe Skinner, Risk Manager, CGST Gail Trotter, Chief Nurse, Midlothian CHP Fiona Watson, Clinical Director, Midlothian CHP James Hendry, Clinical Director, West Lothian CHCP (Minutes 1-5.2) Stuart McLaughlan, Partnership Representative NHS Lothian Mike Winter, Associate Medical Director, NHS Lothian (Chair) Noreen Clancy, Senior HR Adviser, NHS Lothian Ian McKay, Clinical Director, Edinburgh CHP Lynda Cowie, Chief Nurse, East Lothian CHP Sally Lee, Chief Nurse, Edinburgh CHP Tim Montgomery, General Manager, REAS Gerry Power, General Manager, Midlothian CHP Alex Joyce, Partnership Representative, NHS Lothian IN ATTENDANCE: Richard Walter, CHP Secretariat Margaret Douglas, Public Health Consultant (Minute 5.3) Gordon Black, GP Adviser Minutes 1 5.3) Jeanette Morrison, Quality and Accreditation Manager, CGST Item 1 Welcome welcomed attendees and noted a good attendance. He hoped that all CHPs and REAS would continue to ensure that representation would be present at all future meetings. 2 Minutes of Previous Meeting The minutes of the meeting held on 4 October 2007 were reviewed and agreed as an accurate record. Action CHPs/ REAS 3 3.1 Matters Arising Reporting and Assuring Clinical Governance in Primary and Community Services (Minute 9.1 refers) informed the Committee that a Workplan was in the final stages of development. explained that an Incident Report and policy had been

3.1.1 3.2 4. 4.1 4.2 5. 5.1 5.1.1 5.1.2 approved and would be available on the NHS Lothian Intranet shortly. A guidance note would be provided for Quality Improvement Teams with support and advice being offered from the Clinical Governance Team. asked members how they wished to provide/receive updates. The options were reviewed; a verbal report from each CHP/REAS; a copy of any written report provided to local governance committee; or provide a new report. Following discussion, it was agreed that copies of local QIT meetings as provided to CHP/REAS senior management - should be distributed and these to be supported by written or verbal exception reports as necessary. It was agreed that all hosted services should have an opportunity to make an input on a scheduled basis. NHS QIS Clinical Governance and Risk Management Action Plan (Minute 7.1.2 refers) reported that a high level Action Plan relating to work within NHS Board strategic committees had been approved by the Board and would be circulated to the NHS Lothian Healthcare Governance and Risk Management Committee on 18 December. Patient Focus Public Involvement Scottish Patient Experience Programme PD gave members an overview of the current position and indicated that she would be happy to give a fuller presentation at a future meeting. This was agreed. She pointed out that national progress had been slow but it remained the Scottish Government s intention to carry out a national benchmarking survey testing various components of the patient s experience. RW explained that the National Complaints Review Sub-Group had also made slow progress but this was partly due to other factors as detailed in minute 5.1 below. NHS Lothian Equality and Diversity Steering Group The Committee noted the formation of a new group under the chair of Teresa Douglas, non-executive director. Training options in Equality and Diversity needed to be explored across the CHPs. Risk Management Complaints Report : Quarter ending 30 September 2007 The Committee considered the circulated summary of formal and informal complaints activity and were pleased to note that the REAS and CHPs QITs were now reviewing complaints on a regular basis. In terms of performance, the CHPs/REAS were achieving over 82% of responses within 20 working days. RW reported the (Professor Crerar) Review of Public Sector Scrutiny; including Complaints had been published hinting at need for greater oversight of Ombudsman services and suggesting the need for a common complaints procedure for all public sector bodies. This would be progressed by a Working Group during the early part of 2008. Also being undertaken during 2008 was a review of the current NHS Complaints Procedure in Scotland. The Scottish Health Council were PD RW

5.1.3 5.1.4 5.2 5.2.1 5.2.3 5.2.4 5.3 5.3.1 5.4 5.5 tendering for an agency to carry this out on their behalf. The Committee noted that NHS Lothian was a pilot site for Equality and Diversity Monitoring Forms which were issued with every complaint acknowledgement. It was envisaged that the forms would be issued throughout Scotland from 1 April 2008 but wording on key questions was being debated. RW gave an example of one of the specific questions re transgender issues; he suggested that the proposed wording, requiring intimate detail, could put off complainants from pursuing their concerns. PD asked if she could attend the forthcoming NHS Lothian Complaints Forum meeting where the Monitoring Form, roll out of DATIX and other relevant issues were to be debated. DATIX roll-out for CHPs/CHCP JS provided the Committee a progress report on the roll out programme for DATIX. The Committee noted that the Project Implementation Plan had been finalised and reported that approval of licences was currently awaited. GB stressed that this was an opportunity for GPs to become involved in use of DATIX and he hoped many would be encouraged to use it. He stressed that there were no fail safe systems in place. Issues such as what type of information District Nurses etc should record on DATIX had to be considered. Practice Managers would be key to implementing Practice systems and DM suggested that any publicity be targeted through them. PD agreed that is it was critical to get DATIX up and running quickly and especially to ensure that the complaints component was introduced to the Board and CHPs and linked with the existing UHD system. Incident Report Diabetic Retinopathy Screening and Follow Up Dr Margaret Douglas introduced a circulated paper which reported on the findings of an investigation into Diabetic Retinopathy Screening (DRS) and the specific problems identified when a patient who had been screened prior to the introduction of the national programme, had subsequently failed to attend an Ophthalmology appointment (whilst an inpatient elsewhere in the healthcare system) and developed a disease related sight loss thereafter. The Committee wondered how to extract and disseminate the information from the report and in particular how GPs might learn from the incident. It was agreed that the Clinical Governance Newsletter (which was circulated to all GP Practices, should feature an article drawing out the key messages. suggested that the CHP representatives should use this minute to discuss with their particular GP Practice reps. Incident Reports Exceptions from CHPs/CHCP/REAS etc JH advised that a MH patient had absconded from St John s Hospital but had subsequently returned. This was the first time the new alert procedure had been instigated. Scottish Patient Safety Programme Update and Baseline Audits reported that planning for the first phase involving work in acute care was on track but a detailed analysis of the baseline audit data was not yet available. He would report back to a future meeting. He also advised the RW /PD JS / ALL /CHPs

6. 6.1 6.2 7. 7.1 7.2 7.2.1 7.3 8. 8.1 8.2 8.3 9. 9.1 NHS Lothian intention to take forward a Primary Care/ Community / Mental Health programme in parallel with the mandatory national SPSP. Effective Clinical Care Progress within Individual QITs/QIP indicated that a full report from this evaluation would be submitted to the main NHS Lothian Healthcare Governance Committee. suggested that it would be of great interest to have a report with short bullet points at the end of the financial year showing what positive things NHS Lothian had achieved. Lothian Clinical Guidelines Steering Group noted the enthusiasm of acute colleagues on the Group and reported that whilst GPs were represented there was a need for CHP representation and ideally someone with a Mental Health background. asked for nominations. External Quality Assurance NHS QIS Clinical Governance and Risk Management Updated Action Plan assured members that this was being updated and will be circulated NHS Lothian Policy and Implementation NHS QIS Standards/Reviews JM introduced a circulated paper which set out the Draft NHS Lothian Operational Procedure for Addressing Clinical Governance Related Guidance on Safety Alerts/Safety Action/Hazard Notices. It was noted that the paper was going to next EMT for formal approval. In future all external and internal alerts/notices would be sent to and collated at a single point by a nominated senior officer. The Committee noted that JM was going on secondment to NHS QIS and wished her well. NHS QIS Children s Asthma Review Self Assessment It was noted that would report to the next meeting. Child Protection Arrangements and Protection of Vulnerable Adults Action Plans in Response to HMiE Report into Child Protection Services FW indicated that Midlothian CHP had taken full stock of the Action Plans. Oversight Arrangements for PoVA indicated that guidance had been distributed to all practices however local contact names had not been recorded. It was agreed these would be shared locally. Information Governance and Data Sharing with Police and Others updated the Committee regarding an incident and reminded colleagues that it was easier to defend sharing a concern than it was to defend a colleague where information had been withheld and harm had occurred. Advice was available to all through the Caldicott network.. Clinical Governance Briefing Final Draft: Quality Improvement Strategy Healthcare Governance /REAS CHPs

9.2 10. 10.1 10.2 10.3 10.4 10.5 10.6 and Risk Management in NHS Lothian promised to distribute a copy with the minutes. CGST Work Plan 2007-2008 It was noted that and were working on the Clinical Governance Support Team Work Plan and copies would be circulated for discussion at the next meeting. Exception Reports Control of Infection Minutes reported that the Minutes of the CHP/CHCP/REAS Control of Infection Committee were already widely circulated. It was agreed the Committee might wish to consider issues arising from these on a regular basis with an annual invitation to members of the P&C control of infection advisory committee to meet with this group. Practice Incident referred to a recent incident of a GP prescribing for self (not controlled drugs). This may not be illegal but was considered poor practice and the GP had been so advised. The message not to do so would be cascaded. Immunisation Policy In response to a question from PD, it was agreed that this should be addressed through the normal channels and did not require specific reporting to the Committee. Pandemic Flu In response to a question from PD, it was agreed that this should be addressed through the normal channels and did not require specific reporting to the Committee. Falls Patient and Staff Safety In response to a question from PD, it was agreed that this subject should be brought back to the next meeting with JS providing any information he thought the Committee should be aware of. Mental Welfare Commission Report TM updated the Committee on a recent C Report on Mr G. It was noted that all C Reports were published as generic documents for NHS Scotland. TM advised that he actions recommended by C, including a training update on dementia for all medical staff, had been taken forward within REAS. Outcomes from such reports were regularly disseminated across Lothian and advice had been given to staff working in the CHPs. / JS CHPs 11. Date, time and venue of next meeting Thursday, 7 February 2008 1pm to 3pm, St Roque Boardroom, Astley Ainslie Hospital. ALL