Minutes of NHS Shetland Clinical Governance Committee (CGC) Held on Tuesday 27 th October 2015, Board Headquarters Bressay Room Montfield

Minutes of NHS Shetland Clinical Governance Committee (CGC) Held on Tuesday 27 th October 2015, Board Headquarters Bressay Room Montfield Present Malcolm Bell Drew Ratter Chair, Audit Chair In attendance Kathleen Carolan NHS Shetland Director of Nursing and Acute Services Dr Roger Diggle NHS Shetland Medical Director Simon Bokor-Ingram NHS Shetland Director of Clinical Services Dr Sarah Taylor NHS Shetland Director of Public Health Ralph Roberts NHS Shetland Chief Executive) Harold Massie NHS Shetland Public Partnership Forum Chair Emma Garside NHS Shetland Clinical Governance & Risk Lead Martha Nicolson Shetland Island Council Chief Social Work Officer Fiona Smith NHS Shetland Head of Physiotherapy (agenda Item 7 only) Elaine Campbell NHS Shetland, Senior Physiotherapist (agenda Item 7 only) Mary Marsland NHS Shetland Corporate Services Supervisor (minute taker) Barbara Foran NHS Shetland Administrator The committee welcomed Emma Garside, NHS Shetland, Clinical Governance & Risk Lead and Martha Nicolson, Shetland Island Council, Chief Social Officer. Introductions were made around the table. It was noted Simon Bokor-Ingram (SBI) would be presenting agenda item 5 in the absence of Raymond Cross (RC). Agenda Item 6 is to be deferred until the next meeting. Agenda Item 7 would be taken at the end of the meeting. CG 15/33 CG 15/34 Apologies for absence Apologies for absence were received on behalf of Keith Massey, CGC Committee Member, Ian Sandilands, CGC Member & ACF Chair, Dr Catriona Waddington, Raymond Cross, Clinical Director Dental Services, Edna Mary Watson, Andrew Humphrey, Colin Marsland, NHS Shetland Director of Finance and Chris Nicolson, NHS Shetland Director of Pharmacy. Declaration(s) of Interest There were no declarations of interest to note. CG 15/35 Revised Draft Minutes of the meeting held on 19 th May 2015 Page 1 of 11

The revised minutes of the Clinical Governance Committee meeting held on 19 th May 2015 were approved as an accurate record. Draft Minutes of the meeting held on 28 th July 2015 Kathleen Carolan (KC) noted page 6 CG 15/44 local performance data should read National ehealth performance data. The minutes of the Clinical Governance Committee meeting held on 28 th July 2015 were approved as an accurate record subject to this slight revision. CG 15/36 Matters arising & Action Tracker Dr Roger Diggle (RD) informed the committee within the 28 th July 2015 minutes under page 17 of 276 of the pack - CG 15/39 Shared Neurological Pathway with NHS Grampian He had had a conversation with Dr Richard Coleman, Neurologist at NHS Grampian NHS Grampian are happy to develop a Shared Neurological Pathway, they have various initiative ideas. All is in hand but will take time to arrange due to a number of local factors involved. Action Tracker It was noted Neurological Pathways had been discussed within matters arising. It was reported an Ambulance Liaison Group meeting had taken place within the last few weeks following the Strategy and Redesign Committee, where it was asked if a shared corporate risk register could be devised for land ambulance provision as well as air ambulance provision. The risks will be in two parts, one will be the short term issue of paramedic cover overnight and at weekends. The longer term issue of land ambulance provision within the Northern Isles would be addressed as there appears to be inequity in land ambulance provision within the Northern Isles compared with similar island groups. A bench marking exercise has been requested around this which will be presented at a future Strategy and Redesign Committee meeting. It was noted Falls Management was within today s agenda. CG 15/37 Draft Oral Health Strategy for Shetland SBI apologised for the absence of RC and informed the committee this was the first draft of the Oral Health Strategy. It was reported that the first draft of the oral strategy primarily focus on the oral health of the population in its totality. The draft strategy is divided into four parts which are: What is known about the oral health of the Shetland Population How NHS Oral Healthcare is provided in Scotland in comparison to the current position in Shetland Shaping and developing oral health services in Shetland for the future Key points for an action plan An overview of the Draft Oral Health Strategy was given along with the direction of travel for the next five years towards the outcome of Oral Health for All. It Page 2 of 11

was reported a draft action plan is in the process of being developed which will feed into the draft oral health strategy as which would then become version 2. SBI summarised that the strategy does underline the need for more general dental practices as there is room within the market. It was reported the public dental service needs to focus on its core remit alongside a cost effective range of local specialists dental services for patients who do need specialist care. Feedback from the committee was welcomed whether through this forum or separate comments. SBI was thanked for presenting this agenda item in the absence of RC. Drew Ratter (DR) asked what specialist treatment is required within Shetland and what are the arrangements already in place to meet these requirements? SBI stated most dental services you would expect to come across will provide more interventions than others, particularly private dental clinics who would deliver more complex treatment than what is provided at a general dentist surgery. The public dental service also manages adults and children with special needs which require a longer consultation because they are more difficult cases to manage. It was noted this needed to be made more explicit within the strategy. KC commented in terms of the strategic context, it would be helpful if it was clear where the strategic ownership of orthodontic and max fax services was positioned in the strategy document, as these services are delivered in a hospital setting but the clinical pathways are part of/aligned to specialist oral surgery or general dental provision. We need to ensure that the strategy reflects the direction of travel for specialist services, including future sustainability and skill mix. It was noted and agreed another draft will be re-issued which will then be emailed to the committee. The committee commented the strategy had good coverage and was extremely readable. CG 15/38 Revised Summary ISG Workplan 2015/6 It was noted this agenda item had been deferred until the next meeting CG 15/39 Update on Falls Management It was noted this agenda item would be presented to the committee at the end of the meeting. CG 15/40 Update on DNACPR review June 2015 RD informed the committee that this report had been provided by Julie Redpath (JR) who is the Resuscitation and Training Advisor. It was noted this report was being presented due to some concerns around the completion of DNA CPR forms as it was felt these were not being completed as they should be. Following this the committee required follow up reports, it was reported this was the third follow up report being presented to the committee. Page 3 of 11

In the context of the Older Peoples Inspectorate visit last week it highlights the importance of documentation and record keeping which needs to be kept as high priority. This review by JR shows that generally things have improved, however there is room for improvement. Much discussion took place around difficult conversations with patients in relation to their views on resuscitation and how this could be overcome. It was agreed RD would approach Aberdeen to ascertain how they accomplish this and report back to the next meeting. The committee agreed this item would be presented at the next committee meeting for a final time and would then be managed through the Joint Governance Group (JGG) ACTION RD CG 15/41 Update on SACT self-assessment KC reported that CEL 30 (2012) sets out the standards and audit requirements for systematic anti cancer therapy. She noted that Health Boards have been putting in place the new standards for chemotherapy treatment since the publication of the CEL. NHS Shetland opened a new Chemotherapy Unit in November 2014 and this has assisted in the process of moving towards SACT compliance. KDC explained that the Committee had received the audit tool/self assessment to demonstrate current compliance with the standards and areas of weakness and provide assurance that the Cancer Lead Team has oversight of the self assessment process. The CLT reports to the Joint Governance Group (JGG) and to the North of Scotland Cancer Network (NoSCAN) in respect of SACT implementation. Cancer Quality Performance Indicators (QPI s) are monitored through the Waiting Times Group and also reported at a regional level, because our results are part of regional performance as well as local performance because chemotherapy is a shared service with NHS Grampian. KDC noted that where standards are part of local service delivery we are broadly on green. Where standards are part of a regional approach, some are on amber and this is being addressed by NoSCAN and the clinical lead for SACT (and there has been a change in the clinical leadership mid process). KDC noted that she was not signalling any safety concerns with the local chemotherapy service but that there has been slower progress on updating policies and procedures that relate to chemotherapy across the region. It was reported that NHS Shetland are continuing to work with NHS Grampian and more widely with NoSCAN around chemotherapy safety standards and repatriation of services where it is safe to do so with pharmacy colleagues. The committee noted the report. CG15/42 Shared Neurological Pathways Page 4 of 11

RD reported this is shared care between NHS Shetland and Aberdeen. We have a tele-neurology clinic, so new referrals into neurology get assessed by the consultant physicians at NHS Shetland, who will then decide what investigations are needed and whether onward referral to Aberdeen is necessary. It was reported this is currently working well and effectively is a one stop shop if people need to get referred onwards to Aberdeen. It is complicated by the fact that Dr Unsworth undertakes the majority of this work and as reported earlier may be reducing his workload within the next year. It is further complicated by that fact that the neurophysiologist within Aberdeen has retired and no replacement has been found. He has come back to work on a part time basis so they have a much reduced neurophysiology service which is causing a workflow problem. The committee were informed NHS Shetland are working on this with lots of positive ideas and suggestions going forward. This service will evolve but will be different to what it is now. The question was asked if we have the option to go to other Health Boards it was noted that in theory, yes we could. CG 15/43 Children s Services Inspection Plan ST reported the Inspection Plan presents the findings of a joint inspection of services for young people in Shetland which took place between January and March 2015. In many areas NHS Shetland were good however, NHS Shetland were weak in one area and adequate within others. Not wishing to take away from the positive areas it was reported the weaker area was in response to children who are at risk, primarily children on the child protection register or children being assessed for the child protection register. What the inspectors found were variations in how well things were recorded, they couldn t always tell what had happened, not about immediately making children safe but in terms of things changing within children s lives. The way in which the service was able to make things different for those children and families might be about how long they were on the register or about them coming back onto the register. Sometimes the perception is because we are limited in the range of services that we potentially might provide. We felt that by the time the inspectors came and they were looking back over retrospective case notes, a lot of the things they were commenting on were things over the period of a year to eighteen months which had in fact changed a lot, particularly in areas where there were staffing changes. It was felt more work was needed around how the response is actually leading to a change within that child s life and how it measured the outcomes for that, it wasn t that children were not safe or that difficult things were happening to them. A lot of that work has been undertaken since, including picking up the Planning and Improvement Services. There has been a lot of work around taking a more strategic approach to quality assurance and quality improvement for the wider range of children s services. Over the next six months to a year NHS Shetland will be able to show a more systemic and comprehensive approach. It was reported there is a lot of good quality improvement works ongoing with a range of issues showing that action is being undertaken. There will be a follow up telephone meeting with the inspectors within the next couple of weeks to ascertain if we are making progress against the issues they found. It is thought Page 5 of 11

there will be no immediate future inspection. It is hoped the next one will take place within the next three years however; it is possible that they could come and do a smaller visit in the near future. It was reported this was the first integrated inspection which was challenging not only for us but for the inspectors also. RD asked if the action plan include an internal follow up audit of how things are progressing. It was reported it does include continuous improvements. Part of the framework will include what is being done to continuously look at the area so it is less about a follow up audit within the year and more about improving recording on a continuous basis. Discussion followed on the frequency of this report needing to be presented to this committee. It was determined this would be tied into the integrated children s services work for next year which will have the right focus and priorities. It was agreed this should be brought back to the meeting after April 2016 and subsequently on an annual basis unless there were any concerns in which case it would be brought back sooner. RR commented in light of RD s question, that the committee think about what learning we can take around use of assurance and the way in which this framework may develop. How do we use that continuing improvement approach rather than a more old fashioned audit approach to develop the work of this committee. It was agreed to bring back the quality assurance framework once it has been developed and have a discussion on how useful it is as an approach to do quality assurance around a particular area of service as positive lessons could be learned. It was agreed this could be something to discuss at the next committee meeting The committee received the report and approved the action plan. CG 15/44 Risk Management & Adverse Event Quarterly Report RD reported this was a standard report which categorised how we are reviewing events, which type of events and where they are occurring. In terms of how they are managed it was reported there had been a slight improvement, however there was still a number of events that have not been managed. It was reported discussions have taken place on how this process can be simplified and made more effective. The committee were informed a paper will be submitted again once a conclusion has been reached. Discussion took place around the recording of incidents and it was noted that this process is often used as a communication tool describing incidents that have happened. The Datix system was explained to the committee. KC suggested it would be helpful if the Risk Management Group would walk through the streamline processes as it would be good to understand what the abridged pathways will look like. It was noted this was a standing agenda item. SBI enquired if there was any detail around the high and very high level incidents that had been recorded, he wanted to seek assurance that those two incidents were being investigated. RD informed the committee that the report could not identify what the two risks were around and that he would need to Page 6 of 11

seek clarification from Andrew Humphrey to identify these. Once clarification had been sought a response would be circulated to the committee. RD assured the committee all high and very high risks have been investigated or are at least in the process of being investigated. It was agreed within future reports to include the detail of any high and very high risks. The committee noted the report. CG 15/45 Clinical Effectiveness Quarterly Report RD noted this was a quarterly report prepared by Annie Ganguly from Clinical Governance and is a description of all the Governance and Research Governance, Information Governance and Patient Safety Programme work that has been happening in the last quarter. It was noted the reported is being presented for information and gives an overview to the committee of the wide range of activities that have been happening. It was noted that this was a useful report. KC enquired if there was any more detail on the development of the Mental Health Governance Group and the links with Aberdeen. This was raised at the Mental Health Sub Group as they are finding it difficult to get access to the Internal Performance Data of Mental Health within Aberdeen. KC had asked Emma Garside to follow this up with the Clinical Governance Unit in Aberdeen as it sounds like the team themselves are actually trying to make some inroads into having a joint governance focus with Aberdeen, do we know anything more about it other than what has been written? SBI indicated he would ask Martin Scholtz the question in terms of governance for him and the rest of the department ACTION SBI. SBI believed they are linking in with Aberdeen and Alistair Palin around getting direct supervision for Martin and the governance of the team however, he is unsure what the links are for the rest of the Mental Health Team, whether they have a direct link into the wider Mental Health Governance Team Meetings within Grampian, this was something he will ask Martin Scholtz as this was something we should be asking for ACTION SBI. KC reported Emma Garside would pursue through the general clinical governance route as they must have some governance arrangements evident within Mental Health as we would like to know what these are. RD reported Cornhill do have governance meetings as they send copies of their minutes although he did not think NHS Shetland participated in these meetings. They do send relevant information about their services in general and in particular the services that are relevant to Shetland patients. The trouble with the minutes that are sent are they contain information that we should not know as they contain a level of patient identification which is not appropriate for us to see. There is also difficulty in understanding the meaning of the minutes if you have not had sight of the agenda items as a lot of the reports are verbal making it difficult to understand. It was further noted the discussion of performance data does not feature within the governance minutes. ST noted under section 7 of performance management which she understands and it is really helpful, it talks about her having a remit for it, technically she has a remit for performance monitoring for keeping the system up so noted she wanted this to be changed - ACTION. ST also asked if it was possible it would be useful to have a glossary included as there are lots of acronyms which are Page 7 of 11

not explained, also some of the phrases appear to be to technical which would help gain a better understanding. The committee noted the report. CG 15/46 CG 15/47 Care Governance Quarterly Report KC reported again this was another standing item which provides the most recent version of the quality score card which brings together the various improvement work from the Patient Safety Programme and the collaborative. What is new about this report is NHS Shetland have now started to report data about the person centred health and care measures at ward level. We have also continued to meet as a quality group to look at how we can bring together and showcase some of this work in more detail, and to get behind these high level measures through a quality event which will be organised later this year. It is a substantial piece of work, also included is record keeping audit results from ward 1. It was reported in May when we last had an older peoples inspection that we were just at a point of creating a structured health record for the first time, you can see the results within the report on how good their record keep compliance was prior to having a structured document and in comparison what it looks like now. On the basis that it is actually completed this document does help practitioners to record the right things at the right times for patients. The inspectors who were here last week noted that there was a lot of very helpful key care bundles that were included within the document and they commended that we put some of that into some of the records that we have elsewhere in the hospital. The areas progress needs to be made is capturing some of the improvement work within the community setting which includes Primary Care and Mental Health. We are hoping that this quality improvement board will be a vehicle for driving that work forward and being very clear about what it is we want to improve and measure. This will be the focus of this group for the next six months. The committee noted the report. Ambulance Liaison Group Updated Report KC reported there had been a couple of meetings since the Clinical Governance Committee last met. From these meetings some of this issues raised were around leadership of the meetings, however this seemed to be improving with more ambulance personnel input into the meetings. It was felt at the last meeting it was useful that an approach around recording air transfers and the lessons learnt from these was agreed. Land ambulance provision was discussed and the ambulance service reassured the group that arrangements were being put into place. The potential of improving opportunities for shared service was also discussed. It is hoped a more consistent dialogue would be formed around risk and quality issues with the ambulance service going forward. It was noted there should have been a meeting today, however due to the large number of apologies it was mutually agreed to postpone. It was reported there is to be an Oil and Gas Reference Group meeting in November which is specifically to look at the action plan around air transfers from the outer isles. A judgement will be made after this meeting to confirm if a specific group would be needed to drive that work forward or subsume it in some other way. One of the key issues that we are hoping to get a progress Page 8 of 11

report on is where they are at with developing their specialist air desk as this is quite critical to the management of the calls that are coming in and liaison with the coast guard in Shetland. If this is put into place it would give us some assurance that the service is moving forward, if it doesn t then this will need to be reviewed at Strategy and Redesign Committee in terms of it being a corporate risk. It was reported there are a variety of managers from the ambulance service and NHS Shetland sitting on this group along with a variety of senior paramedics who meet every six to eight weeks. The committee noted the verbal report. CG 15/48 CG 15/49 Control of Infection Annual Report ST reported the annual report covers the work of the Control of Infection Committee and the work programme for the control of health care settings and the community for 2014/15. This includes surveillance, training, policy and procedure development, prevention, management of healthcare associated infection and audit. It was thought there were no Clinical Governance concerns around the report and it was merely for information only. The committee noted the report. AOCB Committee Transition It was reported that the Clinical Governance Committee will transition into the Clinical, Care and Professional Governance Committee with a revised membership and a revised Terms of Reference. This is to provide assurance for the Integrated Joint Board and its commissioned services and therefore this will be the last meeting in this format, the next meeting will be in the new format. KDC noted that there would need to be some process to ensure that the membership was correct following the NHS Shetland Board meeting and the IJB meeting, where the Terms of Reference were agreed but the IJB wanted to make some additional amendments e.g. inclusion of a GP rep on the CCPGC. It was noted that the IJB will need to take a lead on this (e.g. ensuring the preferred membership and members are notified of their recommendations) through the Joint Officer. KDC noted that the CCPGC will also need to agree some process for identifying which Non Executive Directors from the Board are going to be on the new committee. SBI informed the committee that the IJB has already considered the recommendation and addition to the Revised Terms of Reference but was unsure if this needed to go back. Ralph Roberts (RR) indicated the NHS Board have agreed the Terms of Reference however the action regarding membership sat with him to check with the terms of reference and to check the Non Executive Directors to see if it was logical for them to transition over. It was noted there would not be a new committee until all this had been confirmed although it was hoped that this would be finalised in time for the next meeting at the end of January. RR noted that the new committee could not take on a quality assurance role in respect of clinical, professional and care governance until the IJB has decided to adopt the strategic plan and adopts all of its Page 9 of 11

responsibilities. It was agreed the process of transition was not far off and it was hoped to have this in hand for the next meeting. Embargoed Item: Medical Revalidation in Scotland 2014-15 RD reported this item was no longer embargoed and was merely for noting. Medical Revalidation is a General Medical Council requirement and is presented for the committee to note. Health Improvement Scotland does require us to do a self assessment every year and this report is on the basis of that. The committee were informed our systems are working very well and there were no action points for this. There are two areas in which we need to work on, one being the number of doctors having an appraisal within a particular year. The reason this was low as with a small organisation doctors might have two appraisals within one calendar year, the reason for this was explained. The other area for slight concern is to make sure we have enough trained appraisers. It was reported one appraiser was in training and should be qualified within two weeks time. This would then be a replacement for Dr Andrew Cooper who is retiring. A replacement for Sarah Taylor who is also retiring will need to be found however RD stated he hoped he had found a potential appraiser. It was noted there is a national shortage of appraisers. An ideal number of appraisers within Shetland would be four, each appraiser is supposed to appraise a minimum number of ten which is technically very difficult to achieve in a small Health Board. We do have a service level agreement with Grampian for 6 appraisers a year should we need them. ScotSTAR Annual Report 2014-15 RD reported this was just for noting. Presented at today s meeting was just the cover paper, there is a booklet which was too large to scan and circulate to the committee but is available if members of the committee wish to read it. Estates: Safety Conversations (issues raised from Patient Safety Conversations) RD informed the committee the report was purely for noting. It was reported there is difficulty in getting estates to follow the patient safety actions through and agreeing a feedback mechanism with estates for estate issues raised and would probably be best for this to be discussed at the JGG rather than at this committee. RR informed the committee it had become a circuitous route for people to raise issues while maybe linked to safety issue, they should be logged with estates. Discussion took place and it was agreed this is a process/procedural issue. A process needs to be agreed for what we are seeing from them, what it is we would expect to see at a Joint Governance Group level, that are coming out of the meetings as key themes and how are we going to make best use of the clinicians time and the teams time if we are going to support this process on an ongoing basis. It was reported that currently nothing is going anywhere outside of the conversation happening within the team. There is a black hole around estates because of the sheer volume which needs to be dealt with as a side issue. What is actually coming out as themes from those conversations needs to be pulled together as a report for the JGG to enable the system to gain more of an idea of what is happening. Page 10 of 11

The committee agreed to remit this to the JGG to look at how they can tighten up the process and feed this back to the Clinical Governance Committee ACTION. Recognition of good practice following undergraduate quality review panel RD presented a letter received from the Scottish Deans Medical Education Group (SDMEG) formally thanking NHS Shetland for the high level standards set for undergraduate training within Shetland. RD informed the committee this praise had been fed back to the clinicians. The committee noted the letter. Update on Falls Management - Presentation KC informed the committee the presentation was a more comprehensive overview on what is occurring within Falls Management particularly as it is such an important cross cutting issue for patients and people within the community. KC gave a detailed overview of the presentation. Fiona Smith and Elaine Campbell gave a full summary on clinical services that are under pinning within Falls Management. The date of the next Clinical Governance Committee is to be held on 28 th January 2016 Page 11 of 11