IT 6F A NOTE OF THE ACUTE SERVICES DIVISION CLINICAL GOVERNANCE COMMITTEE HELD ON WEDNESDAY 2 nd April 2014 AT 10AM WITHIN THE BOARD ROOM, HAYFIELD CLINIC, VICTORIA HOSPITAL Present Mr Nick Barber Ms Lynn Barker Dr Gordon Birnie Prof Ian Campbell (CHAIR) Dr Rob Cargill Mrs Morag Gardner Ms Heather Knox Dr Steven Monaghan Mrs Elizabeth Muir Mr Roy Nelson Dr Susan Smith Mrs Maureen Speedie Apologies Mrs Catherine Cummings Miss Lynn Godsell Mrs Helen Woodburn In Attendance: Mrs S Gilfillan Mrs Lorraine Philip Designation Public Partnership Forum Representative Head of Nursing, Emergency Care Directorate Associate Medical Director, Acute Services Division Emeritus Professor of Medicine, University of St Andrews Clinical Director, Emergency Care Directorate Acting Director of Nursing, Acute Services Division Director of Acute Services Clinical Director, Planned Care Directorate Clinical Effectiveness Coordinator, NHS Fife Public Partnership Forum Representative Clinical Director, Ambulatory Care Directorate Directorate Nurse Manager, Planned Care Directorate Designation Directorate Nurse Manager, Planned Care Directorate PA to Associate Medical Director, Acute Services Division Head of Quality and Clinical Governance PA to Directorate Manager to AMD ASD (minutes) Directorate Nurse, Planned Care Directorate (for Cath Cummings) 1 Welcome and Introductions ACTION Professor Campbell welcomed everyone to the meeting and passed on condolences to Miss Godsell. 2 Apologies for Absence Apologies for absence were noted from the above named members. 3 Minute of ASDCGC Meeting of 15 th January 2014 Professor Campbell thanked Dr Monaghan for chairing the January meeting and advised the unconfirmed minutes had been presented to the NHSF Clinical at the February meeting. The minutes were approved by the Committee. Professor Campbell advised the minutes from 2 nd April 2014 meeting would be presented to the June NHSF CGC adding he would be unable to attend. Dr Birnie confirmed he would be in attendance. 4 Matters Arising 4.1 Action List Professor Campbell referred to the action list and the following points were noted: Created by: Sharon Gilfillan Meeting 2 nd April 2014 1 Created on : 7 th April 2014
Mrs Muir advised the updates for actions were circulated to Professor Campbell, Dr Birnie, Mrs Gardner and the Clinical Directors. Professor Campbell added everyone receives the minute and this new format was to save time and repetition, advising any questions posed would be answered. 5.1 Associate Medical Director, Acute Services Division Report Mrs Muir advised patients diagnosed and treated were tracked via the cancer audit. Dr Birnie added a very full tracker report was produced. Dr Cargill confirmed he was happy that although there was a high volume, every new lung cancer registered was tracked, he also confirmed suspected cancers were registered and tracked until refuted. Dr Birnie agreed he was happy for this action to be closed. 5.2 - Director of Nursing, Acute Services Division Report OPAH. Mrs Gardner advised this was included in the Director of Nursing Report. Professor Campbell confirmed this action can now be closed. 6.3 NHS QIS Neurological Standards Implementation Plan update. Mrs Muir advised Dr Martin Zeidler and Lynn Campbell were actioning this plan. Dr Cargill confirmed letters were sent electronically within Primary Care. Dr Birnie confirmed there was a continuing improvement programme in place and was happy to close this action. 6.1 - Annual Cancer Reports: Lung. Mrs Muir advised the 2012 comparative report was still in draft and will come to our July meeting. Mrs Muir advised that Cancer waiting times are reported by date of treatment. Cancer audit is reported by date of diagnosis. Dr Birnie highlighted the rate of referred surgery was less than Lothian and thought the CGC need to be satisfied with the information on the report. It was agreed that Mrs Muir ask SCAN to be more specific. Action. 6.2 Annual Cancer reports: Urology. Mrs Muir confirmed Mr Janjua had responded, advising the cancer service was not separate from the core and there was a global capacity issue. Mr Janjua had advised although capacity remains static there was a steady increase in cancer. Dr Birnie advised there was a locum in place and Dr Monaghan added there was also a part time Urologist on a higher contract which had slightly increased capacity of staff. Dr Monaghan advised there was a National shortage within Urology and they were currently looking at redesign of the service to address the capacity issues, adding there were regular meetings with the Urology team. Dr Birnie reiterated the very rapid recent increase in this most critical area of cancer and felt it beneficial to continue to have this item in front of the CGC. Following a brief discussion it was agreed to keep this item open for review again in 6 month time. 6.6 - Medinet Quarterly Report. Mrs Muir advised Dr Jones did report back before leaving Fife advising that all Medinet locums should have access to the system. Dr Cargill advised there was reduced reliance on Medinet as arranging at short notice for locums was extremely challenging. Dr Monaghan confirmed that Planned Care do not use the system. Professor Campbell agreed there was now a system in place for new locums to access imaging and the action was closed. 6.1 Endovenous Mech. Ablation for Varicose Veins Dr Monaghan advised this procedure was going well after being endorsed at the last CGC meeting. Dr Monaghan advised this would continue to be audited adding the procedure replaces 1 theatre list and are doing 4/5 per week. Professor Campbell agreed this Meeting 2 nd April 2014 2 Created on : 7 th April 2014
action to be closed. 6.4 National Carotid Interventions Audit Round 5 Dr Monaghan confirmed the patient denomination figure was 2, adding 14 referrals were here but also combined numbers done in the whole region which included Tayside. It was agreed this action be closed. Professor Campbell confirmed the Annual Lung Cancer remain open, and the committee will review Urology in 6 months with the rest of the actions all closed. 5 Executive Leads Clinical Governance Reports: - 5.1 Acute Services Division (ASD) Medical Director s Report Dr Birnie gave apologies and requested the uncensored reports be returned, advising Miss Godsell would send the amended report on her return. Q.1 Dr Birnie highlighted there were a large number of vacancies and advised there was a meeting being held that afternoon with the Directorates, Finance and Human Resources to discuss concerns. Dr Birnie updated there were a number of mitigations in place which were working well and safely ensuring there was no immediate issue with patient safety. Professor Campbell asked if under FOI Act it was possible to know how many consultants appointed in Scotland have come from England. Dr Birnie agreed to ask the Scottish Workforce Group if they have this data available. Professor Campbell was happy that action had been taken and no patient safety was at risk. Mr Nelson was content with the explanation. Dr Birnie confirmed that since the report there were 48 reported consultant positions, although there were 15 in the process of being appointed. Dr Cargill advised that SPRs can be asked to act up but it was determined by their training if they were able to. Dr Monaghan highlighted Neonatal had 5 consultants in Fife but were currently running with 2 locums and one leaving at the end of July to which they had received no applicants. Dr Monaghan also highlighted the 7 vacancies in Anaesthetics however pointed out this was out of a group of 40. Mr Barber asked if these were issues with training hospitals. Dr Birnie acknowledged other District General Hospitals had problems but Professor Campbell reiterated the issues with Sick Kids and Dundee. Dr Birnie agreed that they needed to think 8 years in advance regarding creating a workforce and training specialties. ALL/ GB 5.2 Acute Services Division s Director of Nursing s Report Q.2 Dr Birnie responded to Question 2 advising this followed an announced inspection to the Victoria Hospital in December for Older People in Acute Care which reported 80% of DNACPR forms were not entirely correctly completed. Dr Birnie explained the process and that National Guidance states an indefinite timescale was not acceptable by the inspectors. Dr Birnie sought clarification from Healthcare Improvement Scotland and they have now advised that it is acceptable to say until discharged. Dr Birnie highlighted the inspectors had also looked at the tick box for discussion with family and it was not acceptable to leave blank, however Dr Birnie explained there is the opportunity for consultants to decide not to discuss this with the patient or family however acknowledged consultants were not terribly good at documenting this in the patient record Meeting 2 nd April 2014 3 Created on : 7 th April 2014
Dr Birnie advised Mrs Muir and the Resuscitation Officers were undertaking weekly audits in the wards at the Victoria Hospital and identifying individual consultants where forms were completed incorrectly to whom Dr Birnie would speak to on an individual basis. Dr Birnie also advised that the inspectors will return and he had written to HIS requesting it would be useful if they could advise how they will interpret the form. Mr Barber asked if the relatives were involved. Dr Birnie advised it was a very difficult situation and often relatives had completely unrealistic expectations however pointed out that the inspectors were only auditing whether the form is complete or not. Dr Birnie added that it is only Scottish Government Guidance that we were being inspected on. Professor Campbell thanked Dr Birnie for his full explanation and agreed it was not a legal document. There were no further questions for Mrs Gardner. Mrs Gardner advised the action plan progress update from December 2013 on Older People Acute Hospital would be presented to a future meeting. MG 6 Governance Items: - 6.1 Emergency Care Directorate Clinical Director / Nursing Directorate Report Q.1 & Q.2 Dr Cargill advised that the Clinical Governance Support Team had developed a Clinical Governance Directorate Dashboard, this was now live and monthly reports have been received for January, February and March 2014. Dr Cargill advised Mrs Barker and himself were now able to go over the interactive spreadsheets which linked into Datix Risk Register, Significant Adverse Events, Reducing Harm action plan, Complaints and Mortality Review. Dr Cargill added they were still learning how to use the system but work was progressing well and it was helpful having comments from the CGC on what they may wish to see at future meetings. Q.3 Dr Cargill confirmed any serious complaint/incident would show up on the dashboard. Q.4 Dr Cargill advised he did not wish to duplicate reporting of staffing issues with the Associate Medical Director and Director of Nursing Reports. There was a brief discussion and it was agreed Mrs Muir coordinate the CDs reports to the CGC. Mrs Muir confirmed there will be 5 final SCAN comparative reports being sent soon to the Clinical Directors for reporting in the Directorate reports at the July meeting. /All Mrs Gardner highlighted within the staff issue that Nursing staff were not included in discussions. It was agreed to include Nursing issues in the Directorate reports also. Mr Barber raised the issue of nursing staff morale and absence. Mrs Philip advised there was a very supportive process for staff returning from sick and currently the sickness/absence was running at 4%. Professor Campbell acknowledged there were nursing staff issues and concern over having to advertise posts but this was being dealt with and asked that the CGC be kept informed. It was agreed to include nursing vacancies in the next MG Meeting 2 nd April 2014 4 Created on : 7 th April 2014
Director of Nursing report. Q.6 Dr Cargill advised Mrs Muir had produced a template which he had assumed was for guidance and he had been flexible. Professor Campbell agreed the template should continue to be flexible. 6.2 Proposal for introduction of a new clinical procedure / technique Medical Thoracoscopy Q.1 Dr Cargill advised Dr Ian Fairbairn, Chest Physician was undertaking the procedure and highlighted the following advantages to the Acute Services Division: 1) procedure carried out locally 2) prevents readmissions 3) Capital costs are factored into the Directorate plan 4) Capacity takes up Bronchitis List Dr Cargill advised the procedure rarely has complications adding there is only a small capital cost for the kit. Q.2 Dr Birnie confirmed patients were given an explicit set of instructions on discharge. Ms Knox advised this was the first she had seen this financial development process. Dr Cargill advised it was some time ago but there had a Business Plan meeting before the new Interventional Procedure was brought the for sign off. Dr Birnie requested Mrs Muir send Ms Knox a copy of the policy. 6.3 Planned Care Directorate Clinical Director / Nursing Directorate Report Q.1 Dr Monaghan advised a locum was in place additional to core staff to assist with Urology Cancers, adding the consultant locum was doing elective work which allowed for extra capacity. Professor Campbell thanked Dr Monaghan adding he liked the way Dr Monaghan had highlighted the risks and identified how the Directorate was addressing them with named leads. Dr Monaghan noted this was only a snapshot of the hotspots. Professor Campbell noted Having a Baby in Scotland for Obstetrics was a very good report. 6.4 Annual Cancer Reports Not applicable no reports available. 6.5 Colertal ERAS Professor Campbell thought Mr Yalamarthi s presentation gave a very good summary adding this technique was very well established. Dr Monaghan advised they were looking at developing a laproscopic list but this requires two consultants in the operating theatre at the same time, which makes it an Meeting 2 nd April 2014 5 Created on : 7 th April 2014
expensive procedure. Professor Campbell asked if this effected appointment in the future. Dr Monaghan advised this was very marketable to SPRs. Professor Campbell agreed to drop a note to Mr Yalamarthi thanking him for his presentation. PIC 6.6 5 th Surgical Audit Project of the RCA Report Major Complications of Airway Management in the UK Not applicable no further publication due on this subject. 6.7 Scottish Audit of Surgical Mortality 2012 Not applicable due for publication circa April 2014 c/f to July 2014. 6.8 Scottish Perinatal & Infant Mortality & Morbidity Report 2012 Not applicable due for publication circa 25 March 2014 c/f to July 2014. 6.9 Ambulatory Care Directorate Clinical Director / Nursing Directorate Report Q.1 Dr Smith acknowledged the current local waiting time on referral to treatment is longer than the national guidance Ms Knox advised the referral guarantee overall is legally binding but it is the end result that counts and added Fife was okay at present on the waiting times overall. Dr Smith advised the impact on patients was that we are exceeding targets as urgent work is being prioritised. Dr Smith updated there had been a lot of extra lists, staffing resources, two new staff appointments and weekend working to tackle this issue. Dr Smith advised Radiology was being outsourced to Australia overnight which was currently freeing up 1 session per week. Professor Campbell was happy that action had been taken to address this matter and the CGC were reassured that final waiting times are satisfactory. 6.10 Endoscopy Global Rating Scale Census Report Q.1 Dr Birnie advised NHS Fife performance was not particularly good. Dr Birnie updated there were 16 domains within the Global Rating Scale from Workforce to Patient Care, highlighting the system had been derived in England where 5% is paid to Trusts doing well. Dr Birnie advised Scotland had adopted that report and were trying to drive improvement. There was a brief discussion regarding evidence collation and improvements still required. Dr Birnie advised as Chairman of Endorse he was aware of how to accredit the service. Professor Campbell acknowledged this was a huge exercise and appreciated Dr Birnie s efforts to drive the standards forward. 6.11 Clinical Governance Team Annual Review of Terms of Reference Q.1 It was agreed a non-executive member should be nominated as deputy. Q.2 Professor Campbell confirmed Ms Knox and Mrs Gardner titles to be updated. Mrs Muir agreed to make the changes. GB/ Meeting 2 nd April 2014 6 Created on : 7 th April 2014
Q.3 It was agreed Mrs Muir email Gillian McKinnon for discussion at ASD Divisional Committee. Professor Campbell agreed to discuss further with Mrs Muir once a deputy had been appointed. IC/ 6.12 ASD Clinical Governance Workplan 2014/15 Professor Campbell confirmed there were no questions for the Workplan and this was for information only. Mrs Muir advised this would be on the agenda of every meeting. 6.13 List of Outstanding Items on the ASDCGC Branch of the Clinical Governance Map 13/14 Not applicable no outstanding items to report. 6.14 NHS HIS Update Noted for information only.. 7 Items for Information Only: 7.1 Infection Control Committee Minute of 5 th February 2014 (Draft) 7.2 SRTC Clinical Governance Minutes of 18 th February 2014 () 7.3 Quality, Safety & Governance Minute of 19 th December 2013 (Confirmed) 7.4 Antimicrobial Management Team Minute of 22 nd January 2014 () 7.5 NHS Fife Clinical Policy and Procedure Authorisation and Coordination Group Minute of 14 th January 2014 () 8 Items for Chair to Raise with NHS Fife Clinical (NHSF CGC) There were no items raised. 9 Any Other Competent Business Meeting 2 nd April 2014 7 Created on : 7 th April 2014
Professor Campbell asked if there was a need for Items 7. Dr Birnie confirmed these should be sited on Clinical Governance as it gives the opportunity for CGC to raise any questions. Mrs Muir added that MAP is looked at by Internal Audit, therefore appropriate for these issues to be noted on the agenda. Professor Campbell asked the room be booked for 2 hours for the next meeting. 10 Date of Next Meeting The next meeting will be held on Wednesday 2 nd July 2014 at 2pm in the Board Room, Hayfield Clinic, Victoria Hospital. Meeting 2 nd April 2014 8 Created on : 7 th April 2014