CWM TAF LOCAL HEALTH BOARD

CWM TAF LOCAL HEALTH BOARD Appendix 14a MINUTES OF THE MEETING OF THE QUALITY, PATIENT SAFETY & PUBLIC HEALTH COMMITTEE HELD ON FRIDAY 26 th FEBRUARY 2010, IN RHONDDA MEETING ROOM, YNYSMEURIG HOUSE, ABERCYNON. PRESENT: Prof Vivienne Harpwood - Vice Chair/Non Officer Member (Chairperson) Mrs S Sullivan - Executive Medical Director Ms A Hopkins - Executive Nurse Director Mr S Harrhy - Director of Corporate Services Cllr. C Jones - Non Officer Member Dr S Aslan - Associate Medical Director (Clinical Audit & Effectiveness) Mrs K McGrath - Divisional Nurse (Integrated) Mr D R Williams - Assistant Director of Patient Care & Safety Dr J Geen - Associate Medical Director (Research & Development) Mrs L Guard - Merthyr & Cynon CHC (Chair) Mrs N John - Interim Public Health Director IN ATTENDANCE: Mrs A Gristock - Assistant Director of Nursing/Divisional Nurse (Clinical Support) Mrs C Bevan - Divisional Nurse (Acute) Ms R Woolley - Condition Management Programme, Project Manager Ms J Smith - Condition Management Programme, Service User Secretariat Allison Thomas - Clinical Governance Support Officer QPS&PH/10/17 WELCOME AND INTRODUCTIONS Professor Harpwood welcomed all present to the second meeting of the Cwm Taf LHB Quality, Patient Safety & Public Health Committee. QPS&PH/10/18 APOLOGIES Apologies for absence were received from Mrs Foster, Mrs A Williams, Mr D Lewis, Professor D Mead, Mr H Rowe, Mrs L Williams, Mr G Bell and Mr F Mansell. 1

QPS&PH /10/19 DECLARATIONS OF INTERESTS There were no declarations of interest. QPS&PH /10/20 TO APPROVE THE MINUTES OF THE MEETING HELD ON FRIDAY 16 TH DECEMBER 2009. The Committee APPROVED the minutes following minor amendments. QPS&PH 10/21 MATTERS ARISING Minute QPS&PH /09/05 Refers The Assistant Director of Patient Care & Safety developed and tabled an Annual Work Plan as requested at the previous meeting, to which the agreed Terms of Reference for the Committee were attached to enable the Committee to stay focused. Attention was drawn to pages 11 & 12 of the Work plan which highlights to the Committee key agenda items and mustdo s. All other issues in relation to Quality, Patient Safety and Public Health will align to this Work Plan, which could be added to during the year. The Committee thanked the Assistant Director for producing the plan which was positively received. Committee members were asked for any comments to be forwarded to the Assistant Director of Patient Care & Safety by the next meeting. The Board Secretary/Corporate Director commented that this is an excellent piece of work and suggested that this be shared as a template for all subcommittees i.e. Corporate Risk Committee and request that this format is used throughout the organisation. Reference was also made to the impending development of the Specialist Health Services Committee, which will be hosted by Cwm Taf and the need to amend the Terms of Reference to reflect this development. The Committee RECEIVED the draft Work Plan and asked Committee members to forward any comments to the Assistant Director for Patient Care & Safety. Minute QPS&PH/09/10 Refers The Assistant Director of Patient Care & Safety updated the Committee on the Homicide review action plan in respect of the Mental Health and Accident & Emergency related actions. 7 out of 15 of the recommendations have been implemented or are on-going with 4 on target. It was noted that there has been a slight delay in meeting the set timescales due to the Christmas period and the inclement weather which resulted in some meetings being postponed. Two of the recommendation will now be deferred from January to March for completion date, these being recommendations around the Protocols and Care Pathways. 2

The Committee was informed that Ms Joyce Pegg was today meeting with partners including the Police and would be discussing the need to develop guidelines for a joint community response to similar incidents. The Chair of the Committee informed members that a meeting has been held with the Chief Constable of South Wales Police, the content of which was generally positive with agreement to work jointly with LHB Chairs across NHS Wales. It was also noted that the Chair had written to the Archbishop on this matter. The Committee NOTED the reported update and requested a report on progress with the Action Plan for the next meeting. Minute QPS&PH/09/11 Refers The Divisional Nurse (Acute) updated the Committee in respect of the pre Joint Advisory Group (JAG) assessment of the Endoscopy unit and informed the Committee that Estates have met to undertake a feasibility study in relation to the options available to address the recommendations made in relation to the Royal Glamorgan Hospital Unit. Councillor Jones raised concern in relation to the extent of the required actions given the financial deficit that the organisation is facing. The Divisional Nurse (Acute) advised that commitment has been made through a previous submission for Capital, although accepted that there were also potential revenue implications. The Board Secretary advised that a full financial update, including Capital would be presented to the forthcoming Board meeting. The Divisional Nurse (Acute) added that workforce planning will also be considered alongside the Redesign work. The Committee NOTED the update provided. Minute QPS&PH/09/13 Refers The Executive Nurse Director informed the Committee that the Public Service Ombudsman for Wales (PSOW) was shortly to publish a report under Section 16 powers, in relation to the case of an ENT patient who cancer diagnosis was delayed. A number of the actions associated with the case had already been taken, an update would be provided to the next Committee. The Executive Nurse Director also notified the Committee of the impending inquest of Mr Myron Hall deceased, the subject of a previous section 16 Ombudsman report published in 2009. The Committee NOTED the report and requested an update on actions taken in response to the most recently published report at its next meeting. 3

QPS&PH /10/22 PUBLIC HEALTH, SERVICE USER STORY The Director of Public Health introduced the Project Manager and Customer Contact Development Officer and gave an overview of the Condition Management Programme (CMP). Reference was made to the detailed Committee paper which outlined the work of the Programme and the role of the Customer Contact Development Officer who had been invited to present a service user story. Ms J Smith, the Customer Contact Development Officer, commenced work in June 2009 and is a previous service-user of the programme. Her role is threefold: 1. To proactively improve channels for customers to influence service delivery and feed in their views on service improvement 2. To use her own experience to publicise the benefits (and increase people s understanding) of CMP 3. To use her own experience to inform the team on developing resources, materials, and service development plans Ms Smith s story was positively received by the Committee and the Chair thanked Ms Smith and Ms Woolley for attending. The Executive Medical Director asked about the referral pathway to the CMP and it was explained that currently the only route is through the Job Centre. However, other opportunities for access are under consideration with the Department of Work and Pensions (DWP). The Director of Public Health made reference to the Expert Patient Programme which also helps patients with chronic conditions develop self care programmes. The Committee NOTED the report and thanked Ms Woolley and Ms Smith for attending and sharing a powerful service user story. QPS&PH/10/23 WELSH RISK POOL ANNUAL ASSESSMENT 2009/10 The Executive Director of Nursing presented the report which provided the Committee with an update on the planned arrangements for the Welsh Risk Pool (WRP) Annual Assessment visit planned for 26 th 30 th April 2010, for the 2009/10 assessment period. Only 4 out of the Welsh Risk Management Standards will be assessed, these being: Claims (compulsory) Maternity Operating theatres Accident & Emergency 4

Each of the four standards will have a full in depth assessment, which will involve a review of the evidence files and action plans and interviews with around 10 staff working within each of the standard areas across both District General Hospital sites. The Chair of the Committee enquired whether identified staff are aware in advance of the WRP visit? The Assistant Director of Patient Care & Safety clarified that some staff are notified in advance, but others are selected randomly during the week of the assessment. The Committee NOTED the report and RESOLVED to receive an update in the June Committee meeting. QPS&PH/10/24 PATIENT SAFETY INCIDENT REPORTING QUARTER3 The Executive Medical Director presented the report to Committee. The report compared Quarter 3 activity with quarters 1 & 2 and concentrated on the top three categories of incidents and the work in place or proposed to address related reporting trends. Falls: Patient slips, trips and falls continue to be the highest reported category of incidents. The increase in numbers of reported incidents identifies the increased knowledge and awareness of reporting systems. The Committee was informed of the considerable amount of work that has taken place to develop and implement a Falls Policy. Pressure Damage: There has been an increase in the reporting of pressure damage as a result of awareness raising by the patient safety team and the tissue viability nurses (TVN s). It was noted that through the 1000 Lives Campaign work the area of Pressure damage will be the next area targeted through the general medical and surgical ward care work streams. Delays: There are three main categories contributing to the majority of the reported incidents within this category. a) Delay to treatment due to cancelation or reduction of clinics and patients being placed on unmanaged outpatient holding lists. The Directorates are reviewing their holding lists but there continues to be clinic cancellations and/or reductions. b) Bed pressures specifically where patients have been delayed in their admission pathway through the Accident & Emergency Department. Almost half of these incidents are reported by Intensive Care Units (ICU) whereby patients are fit for transfer out of ICU but there is no available bed for them to transfer to. 5

c) Medical staff delays in attending wards, A&E and clinics. Councillor Jones requested a copy of the Falls policy and enquired as to the reasons patients slip, trip or fall and also enquired whether new staff have a session on this area in their induction programme. It was explained that patients slip, trip and or fall for a variety of reasons and this was the focus of the work in relation to falls risk assessments and implementation of the falls policy. The Falls policy would be sent to Councillor Jones. The Chair of the Committee enquired whether there is any relationship between slips, trips and falls and the complaints being received? The Board Secretary responded that the number of claims for slips, trips and falls has been reviewed and the majority of claims received have been from visitors and not staff. The car park in Prince Charles Hospital has been highlighted as one of the main areas for complaints, however work is ongoing in this area with appropriate signage and lighting in place; the low value claims in this area have been settled. The Divisional Nurse (Acute) informed the Committee that a pool of Healthcare support workers in both Royal Glamorgan Hospital & Prince Charles Hospital have been recruited to help improve supervision and care of patients at increased risk of falls. The Associate Director of Patient Care & Safety reassured the Committee that the Patient Safety Team has a trigger system in place to highlight falls from its Datix system if a patient has already had two falls. The Committee received and NOTED the contents of this report QPS&PH/10/25 HEALTHCARE INSPECTORATE WALES The Executive Nurse Director provided an update to the Committee in relation to the work being undertaken and planned by Healthcare Inspectorate Wales (HIW). It was noted the current healthcare standards are under review with the possibility of a reduction in the number of standards. The process for 2009/10 HIW self assessment was discussed and it was noted that a full assessment of the core healthcare standards 14 (Health & Safety), 16 (Patient Safety), 27 (Governance) and 28 (Clinical Governance) will be completed. In addition to these full assessments will be undertaken on Standards that relate to Dignity and Respect, Safeguarding and Cleanliness and Control of Infection. It was noted that year 2 of the Substance Misuse Thematic Self Assessment Review (5 year programme) is to commence in April 2010, the focus of which will be on the patient journey. The review will involve scenario setting workshops with Substance Misuse Teams and Patients. 6

Unannounced cleanliness spot checks would continue to be undertaken across NHS Wales during the year. Councillor Jones requested that in his role as Board Champion for Cleanliness and Control of Infection that he be forwarded a copy of the most recent HIW report together with the action plan and progress updates. HIW and the Care Standards Inspectorate Wales (CSIW) undertook a joint review of the arrangements for safeguarding and protecting children in Wales and published a report containing its findings and recommendations in October 2009. Cwm Taf LHB has developed an action plan taking into account the 26 recommendations and submitted this to HIW and Regional Office. The Executive Director of Nursing reassured the Committee that the recommendations will be acted upon and Cwm Taf LHB will be compliant by the time a formal report is received. The Committee RECEIVED the report for information and APPROVED the proposed approach to this years HIW self assessment process. QPS&PH/10/26 COMPLAINTS & CLAIMS QUARTER 3 The Board Secretary introduced this report and informed the Committee that during quarter 3. 107 formal complaints were received, which is consistent with previous quarters. It was also noted that the spread of complaints is similar with no significant changes. Within the Acute Division there has been close work with the two Community Health Council (CHC) advocates and the process of complaints was discussed by the Committee. In respect of Trends more complaints are moving towards the Independent Review process or being directed to the Public Services Ombudsman for Wales (PSOW). The PSOW is also accepting more cases than previously. At present 16 complaints are awaiting the outcome of the deliberations of the Independent Review Secretariat and 16 complaints are awaiting the outcome of the deliberations of the Public Services Ombudsman for Wales. The Chair of the Committee requested a more graphical presentation of future reports to Committee and wished the focus to be also on corrective action and learning. The Board Secretary assured the Committee that a Complaints & Claims panel look in detail at each complaint and/or claim and suggested that the minutes from the Complaints & Claims panel be included in the papers for future Committee meetings. The Executive Medical Director made reference to the list of impending Inquests which looks high, but it would helpful if the date of incident and death was included in the report enabling the duration of the process to be clearer. Concern was expressed by the Committee in the length of time some Inquests were pending. 7

It was clarified that this matter was in the hands of the Coroner and could not be influenced by the Health Board. It was noted that the number of inquests linked to the Royal Glamorgan Hospital are considerably higher than those to Prince Charles Hospital. The Assistant Director of Patient Care & Safety informed the Committee that processes are being strengthened across the two Coroner s offices to ensure consistency of information. It was also felt that the list associated with Prince Charles Hospital was incomplete. The Board Secretary informed the Committee of the Integrated Governance meeting where Committee Chairs and lead Executives meet with the Chair and Chief Executive Officer to ensure agendas are shared and linkages are made. In respect of the Clinical Negligence claims spreadsheet received by the Committee it was requested that the estimated % of cost be incorporated as well as the quantum for each case. It was noted that the style is being adapted to respond to the NHS Redress changes which will have significant implications for the NHS The Committee received and NOTED the report and asked that future reports are structured and formatted to the requirements of the Committee. The Committee also resolved to receive the minutes of the Complaints and Claims Panel. QPS&PH/10/27 UPDATE REPORT ON OUTPATIENT CLINIC FOLLOW UP HOLDING LISTS The Divisional Nurse (Acute) presented the report which demonstrated that progress has continued even though it was a significant challenge through December and January. However, it was noted that there has been a reduction of 1733 patients. An updated report was tabled for the Committee. The Committee was informed that this issue is not unique to the Health Board and other NHS organisations across Wales had similar problems with capacity with an emphasis on new patients. Clarity was provided to the Committee in so much as the holding lists are entirely focused on follow-up patients and is seen as good practice if the lists are regularly reviewed and managed. The Executive Director of Nursing identified that some lessons have been learned whilst going through this process which include the more appropriate pathway being to discharge care back to the GP. 8

Planned actions are in place for the Acute Division to move forward and updated Integrated Division & Clinical Support divisional reports will be received at the next Committee. The Executive Medical Director commented that if the partial booking system was working well the pressures would be reduced from Medical Records and it was noted that if harmonisation of patient information across the whole organisation was in place pressures would be greatly reduced. The Committee NOTED the progress and subsequent actions in place. QPS&PH/10/28 SBAR ACUTE DIVISION INTEGRATED GOVERNANCE REPORT The Divisional Nurse (Acute) presented the report for the Acute Division which identified key issues with a risk based approach relating to the Division s Integrated Governance agenda which were aligned to the organisations Strategic Goals, external requirements and the Healthcare Standards for Wales. The detailed report was presented and the following key areas were focused on within the presentation; Financial overspend at month 10 = 557k overspent Insufficient funded nursing establishments to meet dependency, acuity and supervisory care needs of patients leading to continued and increased expenditure on nurse bank. The vacant junior and middle grade doctor posts across specialties and this is impacting on clinical services and costs. Insufficient senior and middle grade medical staff posts in A&E and lack of senior cover out of hours in A&E Departments (trend of out of hours incidents). Patient flow delays and difficulty in achieving 4 hour A&E targets. This increasing impact of the Bowel Screening Wales service on Endoscopy demand and capacity. Lack of service capacity for Orthopaedics, Urology, Ophthalmology Lack of physical capacity in theatre suites and out patient departments Urgent need to replace equipment chairs, mattresses, hoists, oxymeters, dynamaps, sluice masters etc (the Royal Glamorgan site is now 10 years old as is the majority of its equipment). The Division is now leading Cancer services coordination non compliance with standards and targets. Safeguarding children a full review of the paediatric dental lists at RGH and a collaborative action plan to address risks has been developed. January 2010 an increase in incidence of C difficile RGH site, and Norovirus (Dec January) RGH and PCH sites 9

The Divisional Nurse made reference to the corrective action plans in place to address the issues raised and mitigate the assessed risks. The Committee discussed in detail the challenges outlined above and noted the actions in place. It was suggested that the structure of the reports to Committee be changed to ensure risks identified are followed with actions taken in order that the Committee are assured of the actions being taken to address the identified risks. The Board Secretary agreed to take this matter forward. The Committee RECEIVED for information the very comprehensive report and asked that future reporting templates are structured in line with the discussion at Committee. QPS&PH/10/28 SBAR CLINICAL SUPPORT DIVISION The Assistant Director of Nursing/Divisional Nurse Clinical Support presented to the Committee the report to identify the key issues within the Division at the present time and the actions being taken to reduce and minimise risk. The areas discussed included: Medical Records/Outpatients Pathology Radiology Within Medical Records/Outpatients the storage of Medical records is becoming an increasing risk for the organisation and the directorate has provided a comprehensive option appraisal on the future of records storage to the Capital Management dept and an outcome is awaited. The Acute Division is being supported by Medical Records in reviewing their holding lists, however it is a slow process and the numbers are still significant, approximately 15,000 patient case notes are still to be reviewed and reference was made to the impact this has on the records department. Training and development officer has developed a system for collating patient diaries regarding their out patient experience. This has been entered for the NLIAH storyboard competition award scheme. Within Pathology Zero tolerance is now in place on specimen and sample labeling at both Royal Glamorgan Hospital and Prince Charles Hospital a reminder has been sent out to all requestors that all the information regarding tests requested and patient details are completed fully and correctly. If this information is not included the test will not be processed. A questionnaire has been sent out to all GP s to get feedback on the current service along with information on the new zero tolerance protocol. A Coronial Services Group is to be established to ensure compliance with revised Coronial legislation and the Human Tissue Act. 10

The governance arrangements for the provision of chemotherapy are currently under review in order that they meet the required standards. A briefing paper has been produced to establish where the medicines management deficits, risks and concerns are and corrective action will follow. Following internal review of a Digital Mammography incident a final report has been prepared. This details an analysis of the incident, a comprehensive timeline and lessons learnt and the Directorate of Radiology continues to monitor the service and the digital equipment and to date there have been no further related issues. A first meeting has been held to discuss the Radiation Protection arrangements for Cwm Taf LHB. All Wales guidelines are awaited. In order to comply with the latest standards from the Royal College of Radiologists and the Royal College of Paediatrics and Child Health (Standards for Radiological Investigations of Suspected Non-accidental Injury March 2008) all skeletal surveys of infants will be carried out at the Royal Glamorgan Hospital. The Committee were informed that all of the risks identified are in the Divisional risk register and reviewed and actioned on a regular basis by the directorate teams in partnership and with the support of the Division and Corporate teams. The Committee NOTED the report and the reported ongoing work. QPS&PH/10/29 STRATEGY FOR REDUCING SUICIDE AND SELF HARM IN CHILDREN AND YOUNG PEOPLE IN RHONDDA CYNON TAFF The Director of Public Health presented the report to update members regarding the work currently being undertaken in relation to the reduction of suicide and self harm in children and young people in the Rhondda Cynon Taff local authority area. It was noted that across Wales there are a number of strategies which are very helpful which informed the development of this strategy. A joint group from across Fframwaith Children & Young Peoples Partnership, Community Safety Partnership, Local Safeguarding Children Board, Health, Social Care and Well-Being Partnership and the Area Adult Protection Committee was established to address the issue of reducing suicide and self harm in young people. A Strategy has been drafted, the aim of which is to reduce the incidence of suicide, attempted suicide and self harm in Rhondda Cynon Taff. 11

The draft strategy has been presented to a number of local Partnerships / Committees in RCT for agreement: The Committee was informed that the strategy is being presented to various local Partnerships for comments and adoption during the summer. Councillor Jones requested further details of section 4.2.4 of the strategy: Improved front door availability of specialist mental health services at Accident and Emergency Departments to manage more effectively incidents of deliberate self harm and risk taking behaviours and the Divisional Nurse (Integrated) responded that medical staff on call and A&E have 24 hour access to the service, including services for adolescents. The Committee NOTED the report and SUPPORTED the draft strategy. QPS&PH/10/30 INFECTION PREVENTION AND CONTROL UPDATE The Executive Nurse Director gave a verbal update on Infection Control issues: Respiratory Syncitial Virus (RSV) infection reported on the Neonatal unit at Royal Glamorgan Hospital, which had resulted in the closure of the Unit. Ysbyty Cwm Rhondda closed to admissions due to an outbreak of diarrhoea and vomiting. In relation to Neonatal Unit, during the week there were 4 confirmed cases on a Unit of 9 babies. All 4 babies were cohorted in the intensive care area of the Unit, 2 of the babies are critically ill. The Committee was informed that as the virus was a respiratory virus and air borne the Unit was temporarily restricted to admissions, although the Unit in Merthyr was providing support. The Unit had re-opened to admissions from 23 rd February 2010 and the outbreak formally closed. In relation to Ysbyty Cwm Rhondda, there is actual media interest in this matter. It is anticipated that if no new cases are detected then 1 ward may re-open today. In Royal Glamorgan Hospital 1 ward has been closed due to Norovirus with 14 patients affected and 5 staff. In Prince Charles Hospital 1 ward was closed with 11 patients affected and 2 staff. In response to all the above incidents, infection prevention and control processes were being followed. 12

It was noted that there was a significant rise in Clostridium Dificile cases throughout November 2009 January 2010, although the situation had eased during February and returned to the National seasonal average. The Health Protection team of the National Public Health Service had provided support to the Health Board at the Health Board s request and due to the reported Ribotype strains it was apparent that some of the patients were presenting with community acquired infections on admission. It was noted that the All Wales Review on the management of Clostridium Dificile was still awaited even though the anticipated date of receipt was the end of 2009. The Committee NOTED the verbal update report. QPS&PH/10/33 CLINICAL POLICIES FOR APPROVAL The Committee APPROVED the Mobile phone policy The Committee APPROVED the Point of Care Testing (POCT) Strategy and related Policy QPS&PH/10/34 REPORTING COMMITTEES / SUB-GROUP UPDATES The Committee received update reports from the following reporting Committee / Sub Groups; Research & Development Infection Prevention & Control Thrombosis Committee Health Records Committee Point of Care Testing Committee The Committee Received and Noted the updates provided. QPS&PH/10/35 ANY OTHER BUSINESS No other business was discussed 13

QPS&PH/10/36 DATE AND TIME OF NEXT MEETING Future Committee dates: Friday 23 rd April 2010, Cwm Taf Headquarters, Meeting Room, Abercynon. All meetings are scheduled from 09.00-11.30am SIGNED: Professor Vivienne Harpwood, Chairperson DATE:.. 14