MINUTES OF A PATIENT SAFETY AND QUALITY COMMITTEE MEETING Held on Friday, 25 November 2016 between 9.00am and 11.30am in the Conference (Pink) Room, Ground Floor, St Helier Hospital PRESENT: - Pat Baskerville Non-Executive Director (Chair) Elizabeth Bishop Non-Executive Director Ruth Charlton Join Medical Director Peter Davies Director of Strategy, Corporate Affairs and ICT Daniel Elkeles Chief Executive Charlotte Hall Chief Nurse and Director of Infection Prevention and Control Tim Hamilton Director of Communications Caroline Landon Chief Operating Officer Iain McPhee Non-Executive Director James Marsh Joint Medical Director Aruna Mehta Associate Non-Executive Director Sue Winter Associate Director of Workforce IN ATTENDANCE: - Lynn Allen EA to the COO and Director of Strategy, Corporate Affairs and ICT Stella Appiahcubi Consultant Haematologist Annesha Archyangelio Head of Nursing, Infection Prevention and Control 1. INTRODUCTION AND GENERAL BUSINESS ACTION 1.1 Chair s Introduction The Chair welcomed all present to the meeting. 1.2 Apologies for Absence It was noted that apologies for absence had been received from Jill Down (Associate Director of Quality). 1.3 Minutes of the Meeting held on 21 October 2016 The minutes of the previous Patient Safety and Quality Committee (PSQC) meeting held on Friday 21 October 2016 were approved as a true and accurate record with one amendment to note that the Chair of PSQ is not the Chair of the End of Life Steering Group but just a member. 1.4 Action Log from Previous Meeting The action log was reviewed and noted. 1.5 Matters Referred from Other Committees There were none. Page 1
2. PATIENT SAFETY ITEMS 2.1 b c d Integrated Performance Report Month 7 The committee noted the month 7 integrated performance report. James Marsh highlighted the struggle to meet the KPI target for dementia assessment, which may relate to the implementation of changes on Mary Moore Ward and the diversion of the OPALs team. At Executive Committee a method of using the white board for dementia targets could be implemented once VTE targets have been sustained. JM emphasised that missing the target whilst still important has less of an impact on treatment. The Committee noted that the emergency re-admission rate, those patients who had returned to hospital as an emergency with 30 days of the last time they left hospital after a stay, had not been met, that the target had not previously been met and therefore PSQ asked if the target was a realistic one. JM confirmed that the re-admission rate would be a key quality measure for 2017 and nationally monitored. The importance of the correct coding and counting was emphasised and a piece of work would be undertaken on this. It was reported that falls were lowest that they have been since reporting began, but remained a major concern and a marker of care quality. The committee were advised that specific Infection control issues including blood cultures being taken from a palliative care patient, raised questions around clinical appropriateness of looking for sepsis in end of life care patients. The committee agreed that blood cultures should be only be taken in any patient when it may change the management of the patient. CL 2.2 Serious Incident (SI) Summary Report October 2016 Ruth Charlton presented the SI Summary Report for October 2016, noting two SIs had been reported during October and one previous reported incident was de-escalated. Of two reported one was a neonate whose mother was seen regularly during her anti-natal period. The SI highlighted concerns that the notification of delivery was not given to the paediatrician early enough but may require deescalation. In response to a question from the chair it was stated that in such cases a plan for the MDT must be written with mechanisms in place prior to the birth to ensure that the paediatric consultant and team are aware. The second incident the patient was admitted to ED suffering a perforated appendix for which an open appendectomy was performed, three days later the patient s condition deteriorated resulting in a decrease in blood pressure accompanied with an increase in heart rate and respiratory rate. There was a delay in escalation of the patient s condition, the incident was being investigated previously and as such a Duty of Candour lead was identified as well as formal letter sent to the patient s family and discussions with the patient s son, he is aware that the incident has been reported as a Serious Incident. 2.3 Status Report Open Grade 3 Incidents Ruth Charlton asked the committee to note the report, which provided a review of the open incidents on the trust risk management system (Datix,) and the timeliness of closure. As of 12 October, 142 Patient Safety Incidents (PSIs), identified as requiring a concise grade 3, root cause analysis (RCA), 39 of these incidents had been open for 40 working days or less, the committee asked if there were any common themes. Medicine division accounted for 54% of the open incidents. Members suggested an escalation process for incidents open over a certain time frame. Ruth Charlton advised that she signs off level 3 incidents with identifiable harm and that delays were not around escalation but more around process and communication. The committee requested more information on what comprises of a level 3 incident, and requested a paper brought to a future meeting. Page 2
2.4 d. Report on Hospital Acquire Thrombosis (HAT) Stella Appiahcubi, Consultant Haematologist presented the report, which initially was undertaken as the Trusts number of hospital acquired VTE had risen over the past two years. National data estimates two of three cases of Hospital Acquired VTE (HAT) numbers are preventable if risk assessment is properly assessed within 90 days of admissions and the appropriate treatment is administered in a timely manner. The trust have two VTE nurses who, along with clinical risk managers have introduced mandatory training for all clinicians, requiring updating every two years, along with a new HAT reporting tool to review possible HAT incidents, applying the duty of candour in the cases where correct process was not followed and may have resulted in thrombosis. This meant that every case of HAT is investigated by the VTE team and clinicians will be asked to complete an extended RCA in only the cases where process has not been followed. The introduction of the new team huddles in all acute care areas has helped to embed the requirement for VTE risk assessment for all admitted patients, and have reduced although the Trust were still not at 100% compliant. 2.5 Infection Prevention and Control Improvement Plan Annesha Archyangelio Head of Nursing for Infection Prevention and Control presented the paper for noting. The paper provided a summary of the high level Infection Prevention and Control (IPC) issues within the Trust and the proposed improvement plan to aid the reduction of hospital acquired infections (HAI). The main issues highlighted were: - to ensure adequate staffing filling all gaps within the team, to support clinical staff - launch a number of hand hygiene improvement strategies, and embed culture change in hand hygiene, the Non-Executive Directors offered to help with the patients understand the trusts expectations. An improvement plan to be brought back to a future meeting. - to improve vascular line care and management across the Trust, a vascular clinical access nurse was now in place. A detailed improvement plan will be signed off over the next 12 months. - to work with communications on signage around the trust to make staff and patients are aware and ensure all gel containers are full. - Improve compliance with MRSA screening, decolonisation and management, to enable nurses to start treatment straight away not having to wait for a doctor. - process for best practice for patients had been reviewed for C-Difficile, expectation was to see a steady decline. The chair asked that now the access nurse was in post had there been a positive impact, it was confirmed skills for the role. PSQ noted that Annesha had only been in post for a short time. A progress report would be helpful when the improvement plan had been running for a few months. CH AA 2.6 a Optimisation of obstetrics and gynaecology capacity PSQ were asked to approve the paper which outlined a proposal to optimise the consultant cover over the labour wards at Epsom and St. Helier hospitals, to provide a 7 day, 14 hour service between 8am and 10pm e across the Trust, maintaining 98 hours provision at Epsom, but reducing from 132 to 98 hours at St Helier. The planned proposals from February 2017, will help to improve quality, patient satisfaction and continuity of care and patient outcomes regardless of the day of the week. The proposed changes were supported by guidance from the Royal College of Obstetricians and Gynaecologists and were consistent with cover for maternity units with similar numbers within South West London. Clinicians were broadly supportive of the changes and had recently attended a workshop at which they confirmed their agreement. Page 3
The changes would enhance cross site working, which would ensure that the Trust continued to be compliant with 25 out of 27 quality standards. PSQ approved the paper. 3. PATIENT QUALITY ITEMS 3.1 CQC Action Plan Progress Report Ruth Charlton presented the CQC progress report, summarising the monthly progress against the action plan. The plan showed good progress was being made, currently 206 actions have been completed with 12 actions overdue. All divisions with overdue actions were asked to provide comment as to why the target date had not been met. VTE assessments remain under the trust threshold of 95%. Daily reports are being produced to highlight patients that have not had VTE assessment. These reports to be shared with the teams during the white board huddles and significant improvements been seen. A copy of the estates strategy has been sent to the CQC and a number of the actions remained outstanding. Trevor Fitzgerald will be invited to attend the next meeting to provide an update. In response to a question from the committee it was noted that Critical Care intensive outreach service were making good progress, an additional middle tier grade and junior doctors support early assessment on the ward. Eight more intensivists are in place and the service is now able to provide first and second on duty. LA 4. GOVERNANCE/ITEMS REFERRED FROM OTHER COMMITTMENTS 4.1 Complaints action Plan Tim Hamilton presented the report for note. Following a review of complaints handling across the trust and a period of consultation, a revised Complaints Policy was ratified in July 2015. A new structure was established to meet the requirements of the business as usual activity. At that time a back log existed and a targeted approach was taken, with support from a Band 5 bank complaint officer 2 days a week, term time only, good progress had been made over the summer, since then performance had gone down due to staffing issues and a high peek in complaints. Two full time posts have now been recruited to and with additional support the backlog should be over by the end of January. The Director of Communications and Complaints Manager have met with the General Manager for Medicine to discuss issues that have slowed processes and agreed a way forward in reducing the backlog in this particular are An action plan is being put in place focussing on internal audit recommendations and will be brought back to a future meeting. TH 4.2 4.3 Senior Information Risk Owner (SIRO) Report Peter Davies presented the mid-year report to inform the PSQ of progress against the Information Governance (IG) work programme for 2016-2017 and to outline the key priorities and areas of focus. As of 11 November 2016, 70.46% of the Trust s staff had undertaken IG training. 95% of staff are required to have completed this training in order for the Trust to achieve Level 2 against the IG Toolkit. Peter advised that the Board were currently not delivering this standard. Elizabeth Bishop asked Kevin Croft to bring a paper to the next meeting to show completion dat There had not been any Information Governance SIs reported between period April to September 2016. Friends and Family Test Results September 2016 KC Page 4 Tim Hamilton presented the report which provided high level detail relating to response rates and recommend scores for September FFT. Themes highlighted were A & E waiting times, for all areas staff attitude was the primary reason for both positive and negative feedback which demonstrates
the important of high standards of communication and staff behaviours towards patients, some results were very specific and many related to M2, development of staff was important to the ward staff. Regular visits by Tim Hamilton, Sami Young, Lynn Godfrey-James, Charlotte Hall and the nursing staff had been planned. A key deliverable of phase two of the Patient First Programme is to provide a programme of targeted interventions in high priority/low performing areas involving staff of those areas, in identifying plans for improvements through Patient First training. Aruna Mehta requested a report on the Patient First Programme to be brought to the next meeting. The committee suggested that staff are offered the Sage and Thyme development course, which provides key communication skills to NHS staff working with patients. Tim Hamilton to discuss with Pat Baskerville. TH TH 5. MINUTES OF MEETINGS FROM SUB-COMMITTEES AND THE CLINICAL ASSURANCE PANEL 5.1 Clinical Quality and Assurance Committee The minutes of the Clinical Quality and Assurance Committee meeting held on 7 October were received and noted. 5.2 Clinical Assurance Panel The minutes of the Clinical Assurance Panel meeting held on 19 September, 3 October and 31 October were received and noted. 5.3 Information Governance Committee There were no minutes to report. 5.4 Health, Safety and Risk Committee The minutes of the Clinical Assurance Panel meeting held on 15 September were received and noted. 5.5 Improving the Patient Experience Committee There were no minutes to report. 6. ANY OTHER BUSINESS 6.1 To agree any items that need to be referred to any other committee. There were no items. 6.2 Admin review The committee had received a copy of a letter addressed to the Chief Executive, signed by several consultants, expressing their concerns around the proposed changes to the administration services following the recent review. Caroline Landon clarified the case for the change and the current inefficiencies within the service. A full engagement process had taken place with staff including an email from the Chief Operating Officer, and several listening events, but it had been acknowledged that the process of the changes within the Medicine Division had not been good enough. PSQ decided that, in order to implement the engagement and necessary changes properly, the implementation of the Outpatient Booking Centre would be delayed by one month. PSQ agreed that as the committee s next meeting did not take place until 21 January, Caroline Landon would meet the CL Page 5
Chair during the first week in January to update on progress on the engagement and further discussion and seek her approval to proceed. The Chief Executive would respond to the letter. 7. DATE OF NEXT MEETING Friday, 20 January 2016 between 9.00am and 11.30am in the Conference (Pink) Room at St Helier. Page 6