MEETING NOTES Meeting: NHS England Surgical Patient Safety Board Date: 18 th December 2013 Attendees: Professor Norman Williams, Royal College of Surgeons, Chair (NW) Joan Russell, NHS England (JR) Fran Watts, NHS England (FW) Bill Kilvington, College of Operating Department Practitioners (BK) Clare Marx, Royal College of Surgeons (CM) Marisa Mason, NCEPOD (MM) Rita Lewis, AvMA (RL) Anita Dougall (in place of Sara Johnson) Royal College of Obstetricians and Gynaecologists (AD) Matt Fogarty, NHS England (MF) Paul Garrett, RCN (PG) Dominic Tambling, Royal College of Surgeons (DT) Mike Durkin, Director Patient Safety NHS England (MD) William Harrop- Griffiths, Association Anaesthetists Great Britain and Ireland (WHG) Sue Lord ( in place of Mona Guckian Fisher) Association for Perioperative Practice (SL) Cate Quinn, Care Quality Commission (CQC) Tara Renton, RCS Dental Faculty (TR) Apologies: Paul Fogarty, Royal College of Obstetricians and Gynaecologists (PF) David Rowbotham, SALG (DR) Tricia Woodhead, Royal College of Radiologists (TW) Celia Ingham-Clarke, NHS Clinical Director (CIC) Tracy Radcliffe, Royal College of Nursing (TR) Mona Guckian Fisher, Association for Perioperative Practice (MGF) Tom Clutton Brock, Royal College of Anaesthetists Frank Smith, CORESS John Wharton, Warrington Clinical Commissioning Group In attendance: Richard Marks, Royal College of Anaesthetists (RM) Nial Quiney, Royal Surrey County Hospital Abid Shah, Royal College of Obstetrician and Gynaecologists (AS) Minutes taking: Paola Brolis, Admin Support Manager NHS England
ITEM KEY DISCUSSION ACTIONS ACTION BY + DUE DATE A. Introduction and apologies Apologies: As above Introductions: B. Running Record of outstanding actions Nil By Mouth NW: as research is on-going, it should be taken Off the list off the list Deterioration NW: on going MGF looking into NRLS data 004 Manoj Kumar has now met with Deputy Director Complete 06.09.2013 Patient Safety Involving Surgeons in adverse events reporting 005 A meeting took place but still awaiting for data. On going 06.09.2013 Options for utilisation of NRLS data within individual organisations Priorities of the Patient Safety Expert Group Requirement for Deputy for Chair C. Agenda Reports from Surgical Never Events Taskforce next steps NW thanked members for showing interest. JR reported that a consistent approach would be determined for appointing deputy chairs across all Patient Safety Expert Groups MD discussed plan for moving forward on publication of Never Event data: There is the need of being more proactive by releasing info quarterly to reduce the number of FOI enquiries. In the new year, reports will be released on a monthly basis as we need to adapt a more transparent approach to patient safety reporting - on a national basis It was agreed that there is a need to communicate more effectively with the public. It was also recognised that a culture change is needed in the way we educate clinical staff and national standards would support this. Invite deterioration lead (NHS England) to March meeting On going Complete None Ongoing
FW summarised a draft implementation plan for the Taskforce Report and established the next steps: Amendments to the report as agreed with the Taskforce and NHS England Meeting with leads from the Taskforce and NHS England to agree the final version Launch of the report on the NHS England website Feedback from this group is required on the draft implementation plan FW to make amendments Meeting early January Comments to FW Early January Early January By mid January Duty of Candour ELP Quality Improvement Care Bundle A discussion on Duty of Candour was held at the request of the Chief Executive of AvMA: The Chair informed the group that he had now been asked to chair a wider piece of work on understanding the implications of the implementation of Duty of Candour. There were a variety of views and concerns shared which included queries over the threshold of reporting under the Duty of Candour and where responsibility sits. It was suggested that education for doctors should start with undergraduate training at medical school. The group was informed that AvMA are undertaking further work on this issue within their organisation. NQ reported on results of a pilot study in 4 different sites to improve outcomes for patients undergoing Emergency Laparotomy. The key focus on this project is on patient safety. The care bundle includes the following elements: Prompt assessment, resuscitation and escalation of care Early antibiotics NW to feedback to group on next meeting RL to feedback ideas from AvMA at next meeting Discuss again when outcomes of pilot study have been published No set date Early diagnosis and surgery within six hours of decision (consultant-led care) Goal- directed fluid therapy Intensive care unit for all patients Based on recent estimations of incidence and local and national audit data, the team anticipates that implementing the ELPQuIC care bundle across the three trusts could save up to 57 lives and more than 4,300 hospital bed-days per year. If implemented across the NHS, it could save more than 4,000 lives and save more than
300,000 bed days every year. Development of Communicatio n Strategy The group recognised the importance of this study and agreed that they will be keen support the work once it has been published. It was agreed at the last meeting a more effective communication is needed over actions and issues arising from each meeting. Members of the group were asked to share ideas on options to improve communication. Some options included: use of a newsletter use of a bulletin sent out use of emails with attachment FW to work with members of expert group to design Patient Safety Update document It was generally agreed that a Patient Safety Update document could be developed and distributed through this network. Multidisciplina ry documentatio n and surgical checklists Patient Safety Collaboratives Presentation on the importance of the development of a national multidisciplinary theatre documentation. RM provided the background to previous work that had been undertaken by the RCoA and AAGBI to develop standardised theatre documentation that had been developed in his trust. The group were asked whether they were able to identify ways in which they could support this work. It was agreed that the concept of standardised documentation should be supported and recommended that this could be taken forward through ongoing work on implementing recommendations from the Taskforce report. Presentation: NHS England will set up a new national Patient Safety Collaborative Programme across England to spread best practice and build safety skills across the country. It will start in April and will bring together frontline teams, experts, patients, commissioners and others to tackle specific patient safety problems, develop and test solutions, and learn from each other to improve safety. The programme will see the establishment of 15 locally-led and owned patient safety improvement collaboratives covering every geographical part of England by the end of /15. Theatre documentation to be taken forward as part of implementation of the Taskforce report MF will feedback to the group at next meeting. This programme will go to NHS England board for final approval on 24 th January.
AOB Locums Recruitment of Patients Representativ es A concern was expressed in regards to whether the current use of locums is compromising patients safety. JR shared the process being undertaken for the recruitment of Patients Representatives and it was agreed that one additional representative would be sufficient. NW and JR to discuss and bring back to future meeting. Next Meeting: Thursday 6 th, 2-4:30pm