THE STATE HOSPITALS BOARD FOR SCOTLAND CLINICAL GOVERNANCE COMMITTEE Agenda Reference: Date f Meeting: March 2017 Presented by: Title f Reprt: Medical Directr Clinical Frum Reprt Cvering 1 st January 2016 31 st December 2016 Reference Number Lead Authr Cntributing Authrs Lindsay Thmsn Sheila Smith Issue: Apprval Grup Effective Date Review Date Respnsible Officer (eg SMT lead) Clinical Gvernance Cmmittee Lindsay Thmsn Page 1 f 21
1 INTRODUCTION The State Hspitals Bard fr Sctland was asked by the Minister f Health fllwing the 2009 Annual Review t set up a Clinical Frum where senir clinicians regularly meet t cnsider clinical care issues. The Frum deals with all aspects f the clinical care f patients. Its remit was updated in 2015 and reprts annually t the Clinical Gvernance Cmmittee. 2 GOVERNANCE ARRANGEMENTS 2.1 Cmmittee membership Membership is reviewed annually and reprted as part f nrmal mnitring mechanisms. - General Manager - Head f Psychlgy - Head f Allied Health Prfessinals - Head f Pharmacy - Head f Scial Wrk - Medical Directr (Chair) - Nursing Directr - Security Directr - Invlvement & Equality Lead - Assciate Medical Directr - Clinical Effectiveness Team Leader - Lead Nurse - Medical Advisry Cmmittee Chair - Research and Develpment Manager as required - Learning and Develpment representative as required T fulfil its remit, the grup may btain whatever prfessinal advice it requires and invite, if necessary, external experts and relevant members f Hspital staff t attend meetings. Others may attend the Cmmittee n the apprval f the Cmmittee Chair. 2.2 Meetings and Frequency Meetings are held mnthly, n a Wednesday, at 9.30am in the Bardrm. The Chair may cnvene additinal meetings as necessary. 12 meetings were held in 2016. 2.3 Aims and bjectives T review the business f the Prfessinal grups within the State Hspital t ensure a c-rdinated apprach n clinical matters amng the different prfessins and within the cmpnent parts f the Frensic Mental Health Services Managed Care Netwrk T prmte wrk n service design, redesign and develpment pririties and t play an active rle in advising the NHS Bard and Senir Management Team (SMT) n ptential fr service imprvement T prmte the principles f the Clinical Mdel T share best practice amng the prfessins and t prmte multidisciplinary wrking in bth health care and health imprvement; Page 2 f 21
T engage widely with lcal clinicians and ther prfessinals, with a view t encuraging brader participatin in the wrk f Prfessinal grups and multidisciplinary teams T infrm the strategic directin f the Bard thrugh the health planning prcess (Lcal Health Plan) by identifying pririty areas fr imprving the mental health f ur patients. T identify and discuss clinical gvernance issues f cncern; and t ensure the apprpriate management f these. T review and prepare matters relating t the wrk f the Clinical Gvernance Cmmittee. T prvide a frum fr discussin f new ideas T develp and manage utcme measures fr mental health. T liaise with the Research Cmmittee t identify mental health research pririties and t implement research findings. T infrm the develpment f the crprate training plan by identifying training pririties t ensure that clinical practitiners are skilled and cmpetent in the delivery f mental health interventins. T increase the prprtin f care that is evidence based r best practice and prvide guidance n mental health interventins in the areas f risk assessment At the request f the NHS Bard r Senir Management Team, the Clinical Frum may als be called upn t perfrm ne r mre f the fllwing functins: T investigate and take frward particular issues n which clinical input is required n behalf f the NHS Bard and/r SMT, taking int accunt the evidence base, best practice, clinical gvernance, etc., and make prpsals fr their reslutin; T advise the NHS Bard and/r SMT n specific prpsals t imprve the integratin f services, bth within lcal NHS systems and acrss health and scial care. The Clinical Frum will manage its business thrugh a wrkplan, agreed by the Chair f the Cmmittee. This will ensure that the full remit is cvered n a rlling basis. 2.4 Authrity The Clinical Frum is authrised by the Clinical Gvernance Cmmittee t investigate any activity within its terms f reference. It is authrised t seek any infrmatin required t meet its terms f reference frm any emplyee and all emplyees are directed t c-perate with any request made by the Frum. 2.5 Cmmunicatin and Links As utlined in the rganisatinal chart belw, this grup sits between the Senir Management Team wrk and the Clinical Gvernance Cmmittee. Page 3 f 21
ORGANISATIONAL CHART CLINICAL FORUM TSH BOARD Clinical Gvernance Cmmittee Senir Management Team Clinical Frum Mental Health Practice Steering Grup Clinical Wrking Grups/ Multidisciplinary Teams The Mental Health Practice Steering Grup will develp and implement a prgramme f wrk t deliver the agreed strategic pririties. Reference Scttish Executive Health Department (2001) Guidance n the implementatin f the change prgramme. Rebuilding ur Natinal Health Service: The Rle and Terms f Reference f the Area Clinical Frum. 3 KEY PIECES OF WORK UNDERTAKEN DURING THE YEAR : 3.1 Standing Items Natinal Standards and Guidelines Clinical Frum has 2 functins within this prcess. The first is t agree and sign ff that all standards and guidelines received have been sent by Clinical Effectiveness t the mst apprpriate grup fr the gap analysis t be cmpleted. 2016 saw the decisins against 221 guidelines/standards signed ff by Clinical Frum. The secnd is t sign ff accepted variance as required. 16 guidelines/standards were signed ff with tw variances being accepted (this includes MWC reprts etc). Outstanding recmmendatins have been added int actin plans fr the relevant grups which will be reviewed n a 6 mnthly basis. Clinical Effectiveness cnducted a piece f wrk during 2016 with the purpse f streamlining the guideline review prcess. This invlved liaising with all ther Scttish Health Bards, Healthcare Imprvement Sctland (HIS) and the Scttish Intercllegiate Guidelines Netwrk (SIGN). It was agreed at Clinical Frum that the prpsed changes t frmally review Scttish endrsed guidelines and infrmally mnitr NICE guidelines in keeping with ther Scttish Health Bards wuld be implemented with effect frm 1 st January 2017. Page 4 f 21
EPR Updates were received by the grup cvering staffing, reprts, CELCAT and RiO 7. Review f Clinical Gvernance Cmmittee Issues There were n issues brught t Clinical Frum frm the Clinical Gvernance Cmmittee during 2016. 3.2 Annual Mnitring Reprts The fllwing annual reprts were cnsidered and nted by the grup during 2016: Allied Health Prfessins Key pieces f wrk included: Occupatinal Therapy Physical Disability Audit Falls Management Participate Grup Patient Day Prject Outcme Measures Prfessinal Links and Skill Sharing Opprtunities Dietetics Slim & Trim Prmting Health Chices Cnsultatin Allergy guidance Anthrpmetric figures Drama Therapy Music Therapy -The music therapist has prvided individual sessins alng with a regular weekly grup supprted by the psychlgical therapy staff. Pdiatry - This new service allcatin has ensured that ur patients are in receipt f treatment interventins frm specialist pdiatry staff wh are knwledgeable and current in their practice i.e. pdiatric surgery techniques. Physitherapy - Discussins are presently taking place regarding hw the fcus f the service can be amended t supprt the Health Chices agenda and prmte physical activity within ur patients wh are experiencing chrnic physical health issues. Security The Security Annual reprt prvided a breakdwn n the number f patients with grunds access; patient t patient and staff t patient disassciatin; suspensin f detentins; child visit numbers; telephne use and drugs f abuse. Key pieces f wrk included: Security reprts are submitted fr all CPA meetings. Security datix categries have been redefined t prvide better infrmatin. Future reprts will include infrmatin frm this imprved dataset. An audit was undertaken during the year by an independent expert fcussed n physical security. The audit went well, with minr issues identified. The annual physical security audit fr 2016 tk place in April 2016. The 18 mnthly Frensic Netwrk Standards audit is scheduled fr May 2016. Wrk is clse t cnclusin n identifying the items f the physical and perimeter security that may need upgrade r replacement in the next few years. A business case will be develped fr submissin later this year. Page 5 f 21
Scial Wrk Key pieces f wrk included: Thrughut the financial year, the Suth Lanarkshire Cuncil Adult and Older Peple Services Manager prvided direct external management supprt t the Team Leader and engagement with the Chief Executive f The State Hspitals Bard fr Sctland, t ensure the delivery f the cre functins utlined in the Service Level Agreement agreed between bth rganisatins. Scial wrk staff cntinue t have access t training and develpmental pprtunities cnsistent with their particular grade, and the service has cntinued t cntribute t TSH staff training agenda. The successful recruitment f a Head f Scial wrk wh will cmmence in Autumn 2016 Over the reprting perid the service participated in develpmental wrk including in particular: - Scial Wrk representatin at The Psychlgical Strategy Grup - Develpment f the Prevent strategy - Develpment f Family Behaviural Therapy within TSH - The Discharge Variance Analysis Tl - The Suspensin f Detentin prcess - Updated Patient ASP Infrmatin Leaflet - The Visitrs Authrisatin Prcess - Infrmatin Sharing Arrangements between TSH and SLC - Scial Wrk representatin at The Mental Health Practice Steering Grup - Develpments in relatin t ward cnfiguratin and the Clinical Mdel. Key issues/challenges included: T cmplete the discussins currently underway between The State Hspital and Suth Lanarkshire Cuncil, in relatin t the Service Level Agreement fr the perid I April 2016 until 31 March 2019. T agree and implement the draft Infrmatin Sharing Prtcl that is currently under cnsideratin by bth parties. Psychlgy Key pieces f wrk included: The Interventins and Referral Guidance has been updated and circulated widely acrss the hspital. This year we have cntinued t deliver the lw intensity Rad t Recvery grups acrss the hubs. Other grups that have run and / r cmpleted this year are, Mentalisatin Based Therapy (targeting individuals relatinship and persnality difficulties), Life Minus Vilence, Healthy Living Grup (weight management prgramme) and Tune in (emtin management). The team cntinue t wrk with frensic netwrk clleagues t develp and refine prtcls fr psychlgical therapy interventins. The HCR-V3 is nw being used fr all CPA meetings and audits by clinical effectiveness suggest that risk assessment and management plans are being cmpleted at all annual reviews. PTS have facilitated frmulatin meeting with clinical teams and ward based staff, targeting patients wh staff have fund difficult t manage r fr whm interventins and treatments appear nt t be wrking. Cllecting Clinical Outcmes in Rutine Evaluatin (CORE) data at pre and pst interventin stage as well as at the intermediate and annual review stage. Page 6 f 21
Pharmacy The key activities ver the last 12 mnths perfrmed via the Medicines Cmmittee include: The intrductin f mre medicines infrmatin fr patients New guidance n the use f intramuscular medicatin fr acutely disturbed behaviur Agreed a framewrks t supprt medicine management at the GP Clinic Agreed a framewrk fr Pharmacist Independent prescribing at ward level. Prductin f feedback bulletins n medicatin incidents Wrking with the Patient Safety Grup n lcal medicine tpics. Cntinued review f cst effective prescribing within budget savings target The cntinuatin f lcal and natinal clinical audit medicine prjects Additinal key activities in relatin t Pharmacy: The quarterly perfrmance reprts demnstrate Pharmacy cntinue t exceed the KPIs in the SLA arund case review reprts, case review attendance and ICP cmpletin. Implementatin f Pharmacy Technician supprt at GP clinic Implementatin f Pharmacist Independent Prescribing t Ina 1 and 3 Successful visit t the hspital frm the new Chief Pharmaceutical Officer fr Sctland Key challenges fr the next 12 mnths are: Clinical Pharmacist Hub Allcatin Review NHS Lthian Service Level Agreement (SLA) Electrnic Prescribing Supprting Healthy Chices Medicatin Incident Review Clinical Effectiveness The key activities included: Clinical audits int a number f pririty areas with findings/actins being taken frward by varius grups within the hspitals. Examples included: Audit Title POMH Tpic 9 : Antipsychtic prescribing in peple with learning disabilities PMVA Seclusin audit Findings/Actins Excellent cmpliance frm TSH with all areas reaching 100% cmpliance. N actin plan required Reminder t be given t staff t cmplete BEST/PECC and Treatment Plan Objective sectins n the emergency care plan Reminder t be given t staff t cmplete BEST/PECC and Treatment Plan bjectives sectins n seclusin ending frm All frms shuld be placed n RiO t make them mre easily accessible Prescriptin sheet audit Educatinal bulletin t be develped t highlight cmmn prescribing errrs Additin t be made t audit tl t recrd each withheld medicatin as detailed in the Administratin Sheet T2/T3 Audit Review the administratin prcess fr updating RiO whenever a T2 and/r T3 frm is prvided. Ensure that date being put int RiO is cnsistent acrss all Medical Secretaries Page 7 f 21
Antimicrbial Audit Results shuld be shared with The State Hspital GP and dental prescribers t highlight gd practice and key findings Cntinue t prmte imprtance f antimicrbial stewardship at The State Hspital PMVA Initial Admissin Risk Assessment Of the 20 sectins which require t be cmpleted within the Initial Admissin Risk Assessment, the highest level f cmpletin was 94% (previusly 99%) and the lwest level f cmpletin was 34% (previusly 11%). Findings t be discussed at PMVA Review Grup Child Visit Audit The Keeping Children Safe plicy shuld be rewrded t clarify exactly what supervising staff shuld d with cmpleted Feedback Frms fllwing a child visit. The plicy currently states that the Feedback Frms shuld be circulated t the Clinical Team and the Scial Wrk Service. Sme wards return the Feedback Frms directly t the Scial Wrker n their hub whilst ther wards retain the Feedback Frm within a Clinical Team Meeting flder which is then taken t the Clinical Team meeting where the frm is then passed ver t the Scial Wrker in attendance. Leads f Clinical Team meetings shuld actively request t see the Child Visit Feedback Frm within each Clinical Team meeting fllwing a family visit. Infrmatin recrded in Family Centre Security Frms shuld be reviewed befre being signed ff. All staff invlved with supervising child visits shuld make themselves familiar with the Keeping Children Safe plicy. Recrd Keeping Audit Amend the audit tl t recrd which shift has nt input t nursing prgress ntes. Cnsider the audit being brught under the quality imprvement umbrella with bi-mnthly audits being cmpleted until imprvements have been embedded Grunds Access Data prduced fr Mental Health Practice Steering Grup t allw hubs t have an verall psitin fr their hub There have been 221 pieces f guidance/reprts/standards issued during the reprting year that have undergne relevancy checks by the Standards & Guidelines C-rdinatr: Bdy Cunt HIS Best Practice Statement 1 HIS Cnsultatin Paper 4 HIS Draft Standard 4 HIS Evidence Nte 6 HIS Health Technlgy Assessment 2 HIS Lcal Reprt 1 HIS Reprt 4 HIS Standards 2 Mental Welfare Cmmissin 32 NICE Guideline 40 NICE Interventinal Prcedure 31 NICE Public Health Guidance 1 NICE Quality Standards 35 Page 8 f 21
Bdy Cunt NICE Staffing Guideline 1 NICE Technlgy Appraisal 49 Public Health England 1 Scttish Gvernment 2 SIGN Draft Guideline 2 SIGN Guideline 3 Ttal 221 There were 46 that had sme frm f relevance t the hspital and a gap analysis taken thrugh the relevant grup. Other supprt wrk thrugh Clinical Frum included: Prject Title Descriptin 24 hur reprt check This prject takes the data frm the reprt fr admissins, increased bservatins levels, re-admissins, discharges and use f ERBs t allw data analysis int all these elements Diagnsis Audit Checks that the diagnsis between BPAS, RiO and the CPA dcument are cnsistent. Results fed back t individual RMOs t allw actin t be taken Interim CPA audit This prject lked at the first page f the CPA paperwrk and checked it against RiO t check if the data crrelated. Results fed back t clinical teams. Patient Activity (Mull) Data analysis t shw the activity that each patient was undertaking ver a 6 mnth perid (t feed int the patient day prject) Supprting healthy chices Analysed the cnsultatin papers fr the IES service within the cnsultatin hspital Rehab Outings Supprted utings c-rdinatr t redesign all the paperwrk and implement a new prcess that will see the receiving units cmpleting paperwrk Mental Health Practice Steering Grup The Mental Health Practice Steering Grup reprts t Clinical Frum. Achievements frm the Mental Health Practice Grup included: Over the review perid f 1 Octber 2015 t 30 September 2016, there were 8 guidelines reviewed by the MHPSG. Five f these publicatins had varying degrees f relevancy t mental health services within The State Hspital (TSH) and were sent ut fr infrmatin purpses. There was recmmendatin reviews cnducted fr the remaining 3 guidelines. The Variance Analysis Tl was reviewed and the new paperwrk implemented. Reprts are received frm the clinical effectiveness department and actin plans mnitred. A piece f wrk has cmmenced t review hw ften the DRAMS are being cmpleted. This will allw the Clinical Nurse Specialist t mnitr and prmte the tl. Initiating the prject t find ways f making a jurnal club type f activity available fr nursing staff. In discussins with nurse practice develpment, a series f infrmal presentatins are nw being run n a mnthly basis that are delivered by in-huse staff n Saturday mrnings. These will help with the prcess f nurse re-validatin A feedback frm has been put in place that clinical teams are asked t cmplete every time they are issued with the Clinical Outcmes data. The feedback frm asks: What issues d yu identify frm this data? Page 9 f 21
What actin will the hub team take t address these? The respnses are discussed at the meeting with a view t highlight these t Clinical Frum. A wrking grup has been set up t explre the incnsistencies in practice fr engaging new patients ver at the Skye Centre and make recmmendatins fr the way frward. A draft paper has been presented with the next stage t cnsult with clleagues and take feedback n the recmmendatins frm an peratinal perspective. MHPSG cntinue t audit and mnitr a range f data including the fllwing: Seclusins As can be seen there is a steady trend f seclusins increasing ver the last 3 years. April and December saw the highest number f seclusins (6) in a mnth during 2016. Fr 2016 the median, average, minimum and maximum time spent in seclusin was: 2015 2016 Median 28.00 hurs 39 hurs 32 minutes Average 59.71 hurs 78 hurs 40 minutes Min 3.25 hurs 2 hurs 15 minutes Max 468.00 hurs 1154 hurs and 5 minutes In ttal during 2016 twelve patients were secluded. The number f seclusins per patient ranged frm 1 7. Re-admissins During 2016 there were 27 admissins int the hspital. Of these 27, 9 were readmissins. Only ne f the 9 was a re-admissin within 12 mnths. This patient had been discharged t HMP Shtts n 14 th April 2016 and was re-admitted n 5 th September 2016. There were 42 discharges in ttal ver this perid. Fr 2016 the median, average, minimum and maximum time frm discharge t re-admissin was: 2015 2016 Median 8.5 years 8.1 years Average 8 years 9.3 years Minimum 0.3 years 0.3 years Maximum 16.4 years 19.9 years Named Persns Page 10 f 21
The percentage f patients with a named persn (either patient r default nminated) has fallen again in 2016 with 57% having a named persn. This was 57 patients ut f a hspital ppulatin f 111 as at 31 st December 2016. 10 Year Named Persn Trend Data 90% 80% 70% Percentage with named persn 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 2011 2012 2013 2014 2015 2 Advance Statements The percentage f patients with an advance statement has increased slightly frm 2015 frm 29% t 32%. This is still well abve the natinal average. 7 year advance statement data 35% 30% Percentage with an advance statement 25% 20% 15% 10% 5% 0% 2010 2011 2012 2013 2014 2015 201 Key pieces f wrk fr the next 12 mnths Page 11 f 21
Cnslidate the utcmes wrk and mnitr hubs prgress in develping actins plans and the changes hubs make as a result f receiving the utcme data. Implement the recmmendatins f the new patients prject team. Cntinue t receive perfrmance management data frm the PTS and review interventins as apprpriate. Pursue the need fr family interventins as part f the cmpliance with SIGN guidelines fr Bi-plar disrder and Schizphrenia Develp TSH apprach t wrking with patients with diverse ethnic and cultural backgrunds. Cnsider areas f jint wrk t be undertaken with the PHSG PMVA Review Grup Key pieces f wrk carried ut by the PMVA Review Grup between 1 st Octber 2015 and 30 th September 2016 included: Plicy Review -The Grup agreed that it was n lnger apprpriate t have ne verarching PMVA Plicy. As such it was agreed that the existing plicy wuld be brken dwn int individual plicies. This will nw allw fr greater flexibility in adapting individual plicies ging frward. There is a standing item in every meeting in relatin t PMVA Grup Plicy and Prtcl Stck Take. Plicy Gvernance - A schedule has been agreed in relatin t the auditing f PMVA Plicies. Frensic Psychiatric Observatin Plicy - The aim f the audit was t ensure that the new prcess fr lgging increases and decreases in bservatin levels in bth the bservatin level frm n RiO and the medical and nursing prgress ntes is being fllwed. There are issues at present with the cmpletin f frms n RiO and ehealth are currently wrking n these. Disassciatin Plicy - This is part f the CPA audit within the hspital which is currently n a 2 year cycle. Data cllectin has cmmenced, but n reprt will be available until early 2017. Pst Physical Interventin Audit - The aim f the pst physical interventin audit is t ascertain if the key cmpnents f the plicy and prcedures are being adhered t. This is being prgressed via the nurse management grup. Senir Charge Nurses need t ensure that staff are cmpleting frms. Seclusin Audit - Due t the lw number f seclusins there are at the State Hspital an audit is undertaken int all episdes. A revised audit tl is due t be develped t tie in with the revised seclusin plicy. This will ensure mre meaningful data is fed back straight t the clinical team in a timeus manner with an verall reprt ging t the PMVA Review Grup. Initial Admissin Risk Assessment - The aim is t ensure that the initial admissin risk assessment frm is cmpleted as sn as pssible after a patient is admitted. This takes accunt f any physical disabilities the patient may have as well as their BBV status. Mechanical Restraint Plicy Audit - This is a new plicy and mechanical restraint is nt used n a regular basis. The aim f this audit, which will be undertaken each time it is used similar t seclusin, is t ensure that the plicy has been fllwed fr planned and unplanned use f ERBs. PMVA Training - The Grup is prvided with regular updates in relatin t levels f training f staff in relatin t PMVA. These updates are nted nly by the grup as respnsibility fr adequate levels f PMVA training rests with the Health and Safety Cmmittee. PMVA Supprt and Guidance - Members f the PMVA Grup prvide supprt and guidance t staff in relatin t PMVA plicy and practice. This can be thrugh frmal r infrmal requests. Key pieces f wrk fr next 12 mnths include: Page 12 f 21
Cmplete review f PMVA suite f plicies Cntinue auditing use f PMVA plicies and wrk t imprve PMVA practice Cntinue t mnitr the availability, take-up and effectiveness f PMVA training. Cntinue t ffer supprt and guidance t clinical teams in relatin t PMVA practice Deliver n key prjects agreed by Clinical Frum Medical Advisry Cmmittee Key pieces f wrk included: Cnsultant Mves - Changes t the rles f the cnsultants wrking within The State Hspital are discussed in detail at the Medical Advisry Cmmittee meeting. There have been a number f changes in relatin t cntracts with external bdies. These have led t a number f changes with regard t cnsultant respnsibilities and wrklad ver this perid. These have been discussed fully at the Medical Advisry Cmmittee and recmmendatins given t medical managers abut the prpsals. Cnsultant Retirements There were 3 retirements and 3 new cnsultants recruited thrugh the year. The structure and functining f hubs within The State Hspital is discussed by the cmmittee n a regular basis. On 01/06/2015, it was debated abut whether there shuld be an admissin ward in the hspital. At the meeting in February 2016, discussin tk place abut whether there shuld be a lw intensity ward in the hspital. MAC supprted Optin 3 f the Clinical Mdel prpsal, and this is nw being implemented. Discussins tk place with regards t gvernmental mandatry advice that junir trainees d nt wrk mre than seven days in a rw. This fllws the death f a dctr driving hme frm n call duties. Junir dctrs will nw have the Friday ff n leave if they are t perfrm n call duties ver the weekend. This will ensure that n call rtas are cmpliant with Scttish Gvernment health and safety requirements. 3.3 Outcme Measures The Clinical Outcmes Mnitring reprt has cntinued t be presented t the Clinical Frum n a 6 mnthly basis. The reprt prvides data n measures r indicatrs relating t 8 defined area f clinical utcme as nted belw: Mental State - PANSS Vilent Incidents Mving n Transfer List Relatinships Patient Visits Physical Health - BMI Patient Skye Centre Activity Self-Management Patient attendance at Case Review Patient Rate Mental State CORE Sme examples f the data frm 2016 is: Number f Vilent Incidents categrised as Assault Page 13 f 21
Self-Management Patient attendance at Case Review Clinical Frum discusses the results and btains feedback frm the Mental Health Practice Steering Grup in relatin t actins that have been taken by clinical teams t imprve their data. 3.4 Discharge ICP The grup has verseen the discharge ICP prject. The discharge pathway was apprved by the grup in May 2016. A discharge variance analysis tl was agreed by all disciplines within the hspital and this entered the testing phase in December 2016. Future reprts will include data frm the discharge variance analysis tl. 3.5 Clinical Mdel Patients Day Prject The Clinical Frum was asked t review the Clinical Mdel in terms f cntinuity f care and ward cnfiguratin as part f the verall wrkfrce planning exercise undertaken during 15/16. Staff were asked t give their views n the prpsed ptential mdel which aims t increase the activity pprtunities fr patients by releasing hub based staff t deliver activities in the Skye Centre and als within the hubs. This engagement exercise was cmpleted in July 2016. Page 14 f 21
On 17 th August 2016, the Senir Management Team was asked t cnsider 3 ptential ptins fr service change (and als the status qu as an ptin). These were: 1. Shared pre transfer wards acrss 2 hubs with cntinuity f care 2. Pre transfer wards in Lewis and Mull with separate clinical teams 3. Prmtin f patient activity mdel use f third ward in Lewis and Mull. The Senir Management Team debated the merits and limitatins f each mdel and agreed t supprt taking frward a test f change apprach t implement ptin 3, which is the prmtin f patient activity mdel thrugh the use f the third ward in Lewis and Mull Hubs. The benefits f this mdel were identified as it prmting activity, maintaining clinical cntinuity, delivering nursing staff t allw c-utilisatin f Skye Centre, supprting staff develpment, and it being the simplest ptin t try ut as it is the ;least disruptive change fr ur patients. The Directr f Nursing and AHPs was identified as the lead fficer fr taking this wrk frward, and tasked with establishing a structure t prgress same. A small grup has nw been established t undertake initial scping f factrs that need t taken int accunt in taking this prject frward. It invlves leads frm Nursing, Medicine, AHP, Psychlgy, Security and Invlvement & Equality. The Scttish Gvernment and Scttish Health Cuncil have been briefed n ur plans, and the ratinale fr same. A jb descriptin has been written fr a fixed term prject fficer pst t supprt this prject. Funding has been identified, and this will be discussed at SMT n 28 th September. 3.6 Reviews Clinical Frum cntributed t the Annual Ministerial Review held n 18 th Nvember 2016. 3.7 CCTV The utline business case was presented t Clinical Frum in May 2016. This set ut a capital cst f 750,000 t 1,000,000 (plus VAT) fr this prject, with an anticipated recurring revenue cst f 10,000 per annum. The capital element is cvered within the current Prperty and Asset Management Strategy. The business case set ut the multiple steps f the prject. It was agreed that a detailed service specificatin will need t be develped, which will then infrm the tender prcess. Prject risks have been prvisinally scped and a risk rating applied. The verall timeframe fr the prject is apprximately 2 years with the system ging live in April 2018, subject t apprval and funding. Engagement with the patients, carers and staff will underpin the develpment f the prject. 3.8 SUPPORTING HEALTHY CHOICES A plan was apprved by Clinical Frum in Octber 2016. The prject plan included Priritise, risk assess and plan each recmmendatin within Supprting Healthy Chices Reprt: - Preventin: Recmmendatins 1-7 Page 15 f 21
- Reductin: Recmmendatin 8-16 Develp wrk plan and timetable with named respnsible persn fr each recmmendatin. - Review and update Cnsider and integrate int wrk plan where apprpriate, additinal initiatives. Examples - Use f pedmeters - Walk a mile every day Review infrmatin use and requirements - Establish type, surce and quality f basic data n weight / BMI and activity levels - Agree utcme measures t meet aims: separate new and existing patients (preventin and reductin) - Nutritin plans prevalence and use 3.9 Revised Clinical Frum Rle and Remit During 2016 it was agreed that The State Hspital shuld change the remit f the Clinical Frum t be a frum that will supprt the hspital in the cnduct f its business thrugh the prvisin f multi-prfessinal advice maximising the cntributin f clinicians in all aspects f the NHS Bards wrk. In ding s it will represent the integrated multi-prfessinal view f the advisry structures fr Medicine, Nursing, Allied Health Prfessins, and Psychlgy. It will als capture the view f Pharmacy, Security, Scial Wrk, and Invlvement and Equality functins. (appendix 2). It was agreed that a new Clinical Gvernance Grup wuld be established. The remit f the Clinical Gvernance Grup will be: T develp and manage a practive prgramme f quality assurance. T develp and manage a practive prgramme f quality imprvement. T identify and discuss clinical gvernance issues f cncern; and t ensure the apprpriate management f these. T review and prepare matters relating t the wrk f the Clinical Gvernance Cmmittee. T prvide a frum fr discussin f new ideas T develp and manage utcme measures fr mental health. T liaise with the Research Cmmittee t identify mental health research pririties and t implement research findings. T infrm the develpment f the crprate training plan by identifying training pririties t ensure that clinical practitiners are skilled and cmpetent in the delivery f mental health interventins. T increase the prprtin f care that is evidence based r best practice and prvide guidance n mental health interventins in the areas f risk assessment T prmte wrk n service design, redesign and develpment pririties T prmte the principles f the Clinical Mdel T mnitr Natinal Standards and Guidelines external reviews issues identified T mnitr wrk f reprting grups The Clinical Gvernance Grup will manage its business thrugh a wrk plan, agreed by the Chair f the Cmmittee. This will ensure that the full remit is cvered n a rlling basis. 4 AREAS OF GOOD PRACTICE Outcme measures Page 16 f 21
Natinal Standards and Guidelines Clinical Mdel Frum t discuss a wide range f clinical issues Patients Day prject Wrk arund addressing besity 5 FUTURE AREAS OF WORK AND POTENTIAL SERVICE DEVELOPMENTS With the change in the remit f Clinical Frum the main challenge fr 2017 will be t bring the new members tgether and agree n the plan f wrk fr the grup, taking int cnsideratin its rle within the hspital. 6 IMPLICATIONS Staffing & Finance The challenge fr the hspital will be sustainability with year n year savings having t be realised whilst delivering the same high level f clinical care. 7 NEXT REVIEW DATE February 2018. Page 17 f 21
Clinical Frum Prgramme f Wrk 2017 Appendix 1 Area f Review Standing Items (20 minutes) Annual Mnitring Reprts (20 minutes maximum per reprt) Jan 2017 Feb 2017 Mar Apr 2017 May 2017 June 2017 2017 Minutes f last meeting Matters arising update Natinal Standards & Guidelines EPR Review f Clinical Gvernance Cmmittee Issues Plan f Wrk July 2017 AHP PNF Security Scial Wrk Aug 2017 MAC Sept 2017 Oct 2017 Nv 2017 Dec 2017 Psychlgy Pharmacy Interim Reprts (as required) (15 minutes) Special tpics / items fr apprval (15 minutes) Evaluatin f Independent Prescribing Healthy Chices Page 18 f 21
Appendix 2 STATE HOSPITAL CLINICAL FORUM Cnstitutin and Remit 1 Purpse The Clinical Frum functins as part f the verall clinical gvernance structure with the State Hspital s Bard, ensuring: Effective systematic clinical engagement is established and maintained. The prfile and status f the Area Clinical Frum is raised, maximising the cntributin frm clinicians f all disciplines t the planning and delivery f services harnessing their knwledge, skills and cmmitment t the delivery f effective and efficient healthcare. Prgressin f the key dimensins f the NHSSctland Healthcare Quality Strategy. 2 Remit The Clinical Frum will supprt The State Hspitals Bard fr Sctland in the cnduct f its business thrugh the prvisin f multi-prfessinal advice maximising the cntributin f clinicians in all aspects f the NHS Bards wrk. In ding s it will represent the integrated multi-prfessinal view f the advisry structures fr Medicine, Nursing, Allied Health Prfessins, and Psychlgy. It will als capture the view f Pharmacy, Security, Scial Wrk, and Invlvement and Equality functins. 3 Functins The cre functins f the Clinical Frum will be t supprt the wrk f the Bard by: Reviewing the business f the varius Prfessinal Advisry Cmmittees t ensure a crdinated apprach is achieved n clinical matters acrss prfessins and within the cmpnent parts f the rganisatin. The prvisin f a clinical perspective n the develpment f the Lcal Delivery Plan and the strategic bjectives f the Bard. Sharing best practice and encuraging multi-prfessinal wrking in healthcare and health imprvement. Ensuring effective and efficient engagement f clinicians in clinical service design, develpment and imprvement playing an active rle in advising the Bard n ptential pririties fr service imprvement. Cntributing t planning and develpment thrugh ensuring and mnitring that there is apprpriate clinical engagement in service change and imprvement grups. Prviding an integrated lcal clinical and prfessinal perspective n natinal plicy issues. Ensuring lcal strategic and crprate develpments fully reflect clinical service delivery. Taking an integrated clinical and prfessinal perspective n the impact f natinal plicies at lcal level. Engaging widely with lcal clinicians and ther prfessinals, with a view t encuraging brader participatin in the wrk f the Prfessinal Cmmittees. At the request f the State Hspital Bard, the Clinical Frum may als be called upn t investigate and take frward particular issues n which clinical input is required n behalf f the Bard.
4 Cmpsitin The Frum will cmprise f (??) members verall. Members will be drawn frm each prfessinal cmmittee (Nursing/Allied Health Prfessins, Medical, and Psychlgy), and 3 f the members will be chairs f the prfessinal cmmittees (Nursing and AHP, Medical and Psychlgy). The remaining members will be appinted by each prfessinal cmmittee, and will als be made up f representatives frm Pharmacy, Security, Invlvement and Equality and Scial Wrk. If unable t attend any meeting, members may nminate a deputy t attend n their behalf. 5 Qurum N business shall be transacted unless at least 2 f the prfessinal cmmittees are in attendance. 6 Term f Office T help ensure equity f pprtunity, the term f ffice fr members will rdinarily be 2 years, with eligibility fr reappintment fr a further 2 year term, subject t serving a maximum f 4 years. After a break f 1 year, they will again be eligible t serve as members f the frum. 7 Chairpersn The Chair f the Clinical Frum will be chsen by members f the Frum frm the chairs f the prfessinal cmmittees. Selectin f the Chair will be an pen prcess, and all prfessinal cmmittee chairs may put themselves frward as candidates fr the psitin. Electin f the Chairpersn will be based n a majrity f vtes cast The Clinical Frum Chairpersn is respnsible fr: Prviding a multi-prfessinal clinical perspective n strategy develpment and service delivery issues cnsidered by The State Hspital Bard. Prmting pprtunities fr clinicians t be invlved in decisin making lcally. Champining multi-prfessinal c-peratin acrss the clinical disciplines and prviding a vital link between the Bard and the Clinical Frum Actively participating in natinal arrangements t prmte and develp the rle f the Clinical Frum. 8 Vice Chairpersn A Vice Chairpersn f the Clinical Frum will be chsen by the members f the Frum frm amng their number. Selectin f the Vice Chairpersn f the Frum will be an pen prcess and all members f the Frum may put themselves frward as candidates fr the psitin. Electin f the Vice Chairpersn will be based n a majrity f vtes cast. The Vice Chairpersn will deputise, as apprpriate, r the Chairpersn. 9 Frequency f Meetings The Clinical Frum will meet quarterly. 10 Ntice f Meetings A schedule f meetings will be established in March each year fr the fllwing year. 11 Agenda fr Meetings The Agenda fr meetings will be set ne week in advance f the meeting. Standing items will include updates f key issues frm the prfessinal cmmittees, The State Hspital Bard, prgress against the
Clinical Frum Annual Wrk Plan and lcal implementatin f the NHS Sctland Healthcare Quality Strategy. 12 Annual Wrk Plan An annual wrk plan will be develped in March f each year fr the fllwing year and submitted t the Hspital Bard (??) fr apprval. This will cver all aspects f the Frums remit and ensure it cntinue t effectively fulfil its rle and functin. Prgress against the wrkplan will be reviewed at least midyear ensuring it is achieved in full. 13 Executive Directr Lead (Spnsr) The designated Executive Lead (Spnsr) will supprt the Chair f the Frum in ensuring that the Frum perates accrding t / in fulfilment f, it s agreed Terms f Reference. 14 Attendees In recgnitin f the Frum s respnsibility fr champining the lcal implementatin f the NHS Sctland Healthcare Quality Strategy the Clinical Effectiveness Manager will be a standing attendee at the Frum meetings. It is imprtant that the Frum develps strng linkages with the Senir Management Team. Executive Directrs can be invited t attend any meeting f the Clinical Frum. 15 Secretarial supprt Secretarial supprt t the Clinical Frum will be prvided by the ffice f the Bard Secretary. 16 Minutes Minutes f meetings f the Clinical Frum will be prduced in draft within ne week f the meeting date and will be agreed with the Chairman f the Frum, prir t submissin t the next Frum meeting fr apprval. Minutes will be submitted t the next meeting f The State Hspital Bard. Minutes will als be circulated t each Prfessinal Cmmittee and lgged n the Clinical Frum sectin f the Intranet. 17 Mid Year Review f Terms f Reference and Annual Wrkplan In rder t ensure that the Frum functins in accrdance with its agreed Terms f Reference / Remit and delivers its Annual Wrkplan, bth dcuments will be the subject f a mid-year review by the Frum, t identify any areas f slippage n timescales / tasks and put in place any additinal actins t ensure full delivery f the Frum s remit and wrkplan, by the business year end. This review will als prvide an pprtunity fr the Frum t cnsider the need fr any amendments / updates t the Terms f Reference, which in the event, will require t be apprved by the NHS Bard. 18 Annual Reprt The Frum will submit t the State Hspital Bard, an Annual Reprt encmpassing the name f the Frum; the Frum Chair; members; the Executive Lead (Spnsr) and fficer supprts / attendees; frequency and dates f meetings; the activities f the Frum during the year, including cnfirmatin f delivery f the annual wrkplan and review f the Frums Terms f Reference; imprvements verseen by the Frum, matters f cncern t the Frum. In additin the annual reprt which will be circulated t the prfessinal cmmittees, heads f prfessins fr further disseminatin acrss the rganisatin and lgged n the Clinical Frum sectin f the intranet.