CLINICAL GOVERNANCE COMMITTEE
Report by Sarah Wedgwood, Chair, Clinical Governance Committee
The Board is asked to:- Note that the Clinical Governance Committee met on 11 February 2014 with attendance as noted below.
- Note the Assurance Report and agreed actions resulting from the consideration of the specific items detailed below.
- Note the items for discussion at the next meeting to be held on 29 April 2014.
Committee Members:Ms Sarah Wedgwood, Chair
Dr Ian Bashford, Medical Director
Dr Paul Davidson, Clinical Director, North & West Operational Unit
Dr Michael Hall, Clinical Director, Argyll & Bute CHP (videoconference)
Dr Roderick Harvey, Associate Medical Director, Raigmore
Dr Rhona MacDonald, Non-Executive Director
Mr Alan Simmons, Public Member
Dr Ian Scott, Clinical Director, South & Mid Operational Unit (till 10.30am)
Dr Margaret Somerville, Director of Public Health
Mrs Catherine Stokoe, Infection Control Manager
Mrs Katherine Sutton, Associate Director, AHPs
In Attendance:Ms Ayleen Austin, Midwifery Team Leader
Mrs Mirian Morrison, Clinical Governance Development Manager
Ms Brenda Wilson, Lead Nurse, RaigmoreHospital
Miss Irene Robertson, Board Committee Administrator
Apologies–Mr Garry Coutts, Ms Elspeth Caithness, Mr Graham Crerar, Ms Caron Cruickshank, Dr Michael Foxley, Dr Iain Kennedy, Ms Heidi May, Ms Elaine Mead, Mr Bill Reid, Mr Michael Roberts and Mr Brian Robertson.
1ITEMS FOR DISCUSSION
The items discussed at the meeting are noted below:
(i)Case Study
(ii)Questions from Lay Members
(iii)Emerging Issues
(iv)Clinical Governance Committee Work Programme 2014
(v)SPSO Cases 2013 – 14
(vi)Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions
(vii)Care for Older People in Acute Hospitals
(viii)Clinical Governance Framework – Exception Reports from Operational Units
(ix)Complaints
(x)Incident Management
2ITEMS FOR DISCUSSION AT NEXT MEETING ON 29 APRIL 2014
- Case Study
- Questions from Lay Members
- Emerging Issues
- Complaints
- Incident Management
- Weekend admissions and admissions on public holidays
- Mortality Rates
- Bereavement Services and New Death Certification Guidance
- Older People in Acute Care
- Clinical Governance Committee Annual Report 2013 – 2014
3CONTRIBUTION TO CORPORATE OBJECTIVES
This performance report demonstrates how NHS Highland is achieving its corporate objective of ensuring that services delivered are of high quality and clinically effective.
4GOVERNANCE IMPLICATIONS
This performance report has a direct impact on clinical governance and demonstrates performance against responding to complaints, clinical effectiveness activity, patient safety and NHS Healthcare Improvement Scotland reviews.
5IMPACT ASSESSMENT
This report does not require impact assessment.
Sarah Wedgwood
Chair, Clinical Governance Committee
21 March 2014
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CLINICAL GOVERNANCE COMMITTEE ASSURANCE REPORT 11 FEBRUARY 2014
1) TOPIC: CASE STUDYIssues/Risks / Assurance / Actions
The Committee considered a complaint in relation to paediatric day case surgery which had been referred to, and upheld by, the SPSO. The main issues related to discharge arrangements, communication with the child’s family regarding aftercare, and follow up treatment. It was suggested the Intermediate Discharge Letter (IDL) would address these issues in large part in terms of patient safety and the Committee recommended that IDLs should be completed and copied into SCI Store in respect of all patients before they leave hospital. The pressures within the organisation that impact on the ability to achieve 100% completed IDLs prior to discharge were acknowledged but it was suggested there was also a need to review the current discharge policy to ensure fitness for purpose.
There is an issue around staff capacity to investigate complaints to the necessary level to ensure all the issues are addressed. The quality of response letters also requires to be further improved and the need for clinical input to responses was highlighted. Follow through of actions and dissemination of learning is equally important and this part of the process needs to be improved. It was noted there are no dedicated complaints officers within the Operational Units. / An action plan has been developed in response to the SPSO recommendations.
The Committee sought future assurance from Executive Leads that there would be a review of the current discharge policy to enable 100% completion of IDLs prior to discharge.
A considerable amount of training in relation to investigation of complaints has already been undertaken, and continues to be delivered to officers involved in conducting investigations. / Review of discharge policy to be undertaken.
Action: Executive Leads
2) TOPIC: QUESTIONS FROM LAY MEMBERS
Issues/Risks / Assurance / Actions
There were no issues raised.
3) TOPIC: EMERGING ISSUES
Issues/Risks / Assurance / Actions
The Audit Committee had referred an issue to the Clinical Governance Committee relating to Consultant Contracts. It was noted a significant number of consultant job plans had not been signed off. There was need to ensure job plans
reflect realistically what clinicians are able to do within their contracted hours to provide quality care. Capacity and demand planning is key. Given the geography of the Highland area travel time to and from peripheral clinics would also need to be factored in. / Work is ongoing to complete the outstanding job plans, and work on next year’s cycle is already underway. / An update on the position to be prepared for either the April or July 2014 meeting of the Clinical Governance Committee.
Action: Ian Bashford
4) TOPIC: ASSURANCE REPORT FROM 9 DECEMBER 2013 AND ROLLING ACTION PLAN
Issues/Risks / Assurance / Actions
Bereavement Services and new Guidance on Death Certification:
Under the new guidance one in ten death certificates will be scrutinised before issue by the local investigating officer. Impact of delays in obtaining death certificates on families and relatives of the deceased.
It was noted there is a requirement for the system to be completely electronic by 2016.
The necessary software is not yet available, a paper based system will continue meantime.
ACPAs:
Need to ensure that the necessary discussions with patients on a range of issues are taking place.
There is need to consider how the information contained in ACPAs can be accessed by secondary care clinicians and to assess its usefulness in the secondary care setting. It was noted that in the ADASTRA system, which is available to secondary care although there are some difficulties in accessing it, the ACPA is attached to the Emergency Care Summary (ECS). It was acknowledged ACPAs and ECS contain different sets of information. / The Committee will consider bereavement services at its next meeting along with issues identified in relation to the new arrangements to meet the legal requirements for death certification and the implications thereof.
ACPAs:
The Committee is seeking future assurance that the important information relating to patients eg DNAR, power of attorney, living wills, is being used. / Briefing paper to be prepared for the April 2014 meeting.
Acton: Katherine Sutton/Derek Brown
ACPAs:
To confirm a process is in place to ensure the transmission from primary to secondary care of individual personal details and relevant personal information into Emergency Care Summaries for use in the acute care setting.
Action: Ian Bashford / Bill Reid
With reference to the above it was agreed to arrange for an audit to be undertaken within secondary careof the utilisation and value of the information contained in ACPAs.
Action: Ian Bashford/ Bill Reid
4.1 MATTERS ARISING:
Issues/Risks / Assurance / Actions
Draft Clinical Governance Committee Work Programme 2014:
Some work to be done in respect of scheduling attendance by reporting committee chairs and representatives to present annual and exception reports. Issue of availability/capacity.
In terms of governance and reporting arrangements should operational issues highlighted in reporting committees’ annual reports be included in the risk register?
The Chair referred to proposals regarding the future of the Spiritual Care Committee.
Need to consider ways of fostering a clearer understanding of spiritual care and embedding it in everyone’s practice, acknowledging the diversity of people’s faiths and beliefs and the wider definition of health to include mental as well as physical well being. / A governance review is underway which will consider reporting arrangements and accountability.
The Spiritual Care Strategy has been consulted on and will be presented to the Clinical Governance Committee on an annual basis with exception reporting throughout the year where applicable. / Committee members views to be sought in relation to a governance framework and how the committee gets assurance from its reporting committees.
Action: Chair
SPSO cases closed and open during 2013 – 14:
Report received detailing closed and open cases referred to the SPSO. Recurring issues relate to record keeping, communication, discharge and follow up arrangements, and the complaints process itself. Further work requires to be done to improve on these areas.
Local circumstances and procedures in place may impact on the organisation’s ability to implement SPSO recommendations within the specified timescale. It was suggested a representative of the SPSO be invited to a future meeting to discuss this and other related issues. / Considerable training has been provided to officers dealing with complaints however more work needs to be done.
The Committee is assured that all actions arising from SPSO recommendations are entered on the Datix system and assigned to appropriate locality managers for completion and to confirm any exceptions to the Committee. In addition an alert system has been established enabling the Clinical Governance Support Team to ensure follow up.
. / With regard to cases referred to the SPSO, the following actions were agreed:-
- Action plans developed in response to SPSO findings to come to the Clinical Governance Committee.
- Recommendations and actions arising from current cases to be reviewed in order that assurance can be given to the Committee that the loop is closed.
- A record of outstanding SPSO cases to be appended to every complaints performance report to the Committee.
Agreed to invite a SPSO representative to visit Highland and go over a number of their recommendations to discuss their applicability in terms of a local context eg provision of remote and rural healthcare and to sharing best practice.
Action: Chair
Revised Draft Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions:
A few amendments were suggested in relation to some of the terminology used in the document.
In addition to the general consent form which is currently out for consultation there is a range of consent forms relating to specific procedures. The Committee would need to be assured that these forms have been validated and approved as fit for purpose.
There was need to raise awareness of the revised policy among both health professionals and patients.
A query was raised regarding the dissemination of the policy and its applicability to health professionals who have transferred to The Highland Council. / The Committee agreed that the revised policy could be ratified subject to the changes in terminology discussed and validation of the consent forms referred to in the document.
Awareness raising and training will be provided to ensure health professionals adhere to the policy.
With regard to power of attorney, guardianship, etc the policy addresses situations where patients lack capacity to give or withhold consent. / Agreed amendmentsto be made to the Policy and confirmation obtained that the forms have been validated.
Action: Mirian Morrison
Clarification to be sought in relation to the applicability of the policy to health professionals now employed by The Highland Council.
Action: Ian Bashford
5) TOPIC: CARE FOROLDER PEOPLE IN ACUTE HOSPITALS
Issues/Risks / Assurance / Actions
The Committee received the report of the Healthcare Improvement Scotland inspection visit to RaigmoreHospital which took place on 24 – 26 September 2013. A number of areas were identified for improvement.
It was felt that several of the key issues highlighted in the report could be applied to the care and treatment of patients generally and not just to care of older people. It was suggested that some of these could perhaps be progressed through the ‘iMatter’ initiative.
A point was raised regarding the importance of weight as a factor in health and a recommendation was put forward that patients should be weighed as a matter of routine. / The report highlighted several areas where NHS Highland is performing well in relation to the care provided to older people in acute hospitals. An action plan has been developed to address the areas identified for improvement. / The action plan developed in response to the report is part of a bigger piece of work encompassing several work streams (Food, Fluid & Nutritional Care, Dementia, Cognitive Impairment etc) which will be reported on at the April 2014 meeting.
Action: Katherine Sutton
6) TOPIC: CLINICAL GOVERNANCE FRAMEWORK
Issues/Risks / Assurance / Actions
Revised Reporting Template / Exception Reports from Operational Unit Clinical Directors:
North & West Operational Unit:
Two exception reports using the revised reporting template were received and noted. It was acknowledged the process needs to be further refined for the purpose of bringing relevant, high level issues to the attention of the Clinical Governance Committee. Further consideration also needs to be given to how the template can be used as a tool for identifying and sharing key learning points.
RaigmoreHospital:
A Divisional reporting system is in use fulfilling much the same function as the template. Consideration to be given to using the template to report issues to the Clinical Governance Committee.
Minutes of meetings of Operational Unit Quality & Patient Safety Committees:
The following minutes were received and noted:
North & West 6 November 2013
- South & Mid 14 November 2013
- RaigmoreHospital 12 December 2013 and 9 January 2014
North & West Operational Unit:
The template has been found to be a useful operational tool, providing a means for all professional groups within the Operational Unit to note issues and exceptions which can be escalated as required within the Unit.
RaigmoreHospital:
The Committee was assured of systems in place for identifying and escalating issues as appropriate. / North & West Operational Unit:
Agreed the reporting template would continue to be trialled in North & West Operational Unit.
Action: Paul Davidson
RaigmoreHospital:
Exception report from RaigmoreHospitalusing the reporting template to be submitted to the July 2014 meeting.
Action: Roderick Harvey
8) TOPIC: COMPLAINTS
Issues/Risks / Assurance / Actions
The Committee received and noted the complaints performance report as at November 2013. For future reports it was suggested it would be helpful to have separate run charts for simple and complex complaints; the word “targets” to be replaced with “observed over expected number” and actual figures to be included. It was proposed that a complex complaint be tracked through the system to try and quantify the time spent on the investigation.
The major issues identified with regards to the complaints process relate to thoroughness of investigations, quality of response letters, follow through of actions, dissemination and sharing of learning.
The report of Healthcare Improvement Scotland’s review of NHS Boards’ Annual Reporting on Feedback, Comments, Concerns and Complaints 2012/13 was circulated. It was noted some Boards did not produce all the required information, others provided a fuller account. / A complaints dashboard is being developed which in addition to providing details of complaints received will also indicate whether they have been upheld.
Consideration is being given to developing a framework for future Board reports to ensure consistency.
The Committee received assurance that NHS Highland is doing some pro-active work in relation to inequalities. / Future complaints reports to be amended as discussed.
Action: Mirian Morrison
Discussion to take place with the Chief Executive regarding the complaints process, the issues identified and how to address them moving forward, the establishment of a dedicated complaints officer post covering the whole Highland area to be explored.
Action: Chair / Ian Bashford / Mirian Morrison / Elaine Mead
9) TOPIC: INCIDENT MANAGEMENT
Issues/Risks / Assurance / Actions
The Committee received and noted the performance report in respect of Quarter 3.
Issue around initial assessment of incidents being inputted to Datix – risk of “near misses” which could potentially have become major issues.
Healthcare Improvement Scotland (HIS) Rapid Review of Safety and Quality of Care for Acute Adult Patients in NHS Lanarkshire:
Implications of recommendations arising from the review for NHS Highland.
Seminar on Learning from Adverse Events 22 January 2014:
Some concerns expressed about the Serious Event Review process which is time consuming and becoming bureaucratic. / Changes have been made to the instructions contained in Datix to assist officers with the initial assessment of incidents being entered on Datix. Managers also have a responsibility to review incidents and regrade them if appropriate.
Multidisciplinary short life working group to be establishedto consider implications of the review report for NHS Highland and identify issues to be addressed. A gap analysis is being undertaken which it is anticipated should be available for July CGC.
Some very useful debate took place at the Seminar and further events are planned. / An update on the Datix system in relation to developments/improvements and feedback from staff to be prepared for the April 2014 meeting.
Action: Mirian Morrison
Gap Analysis to be submitted to July CGC.
Action: Mirian Morrison
10) TOPIC: MINUTES FOR INFORMATION
Issues/Risks / Assurance / Actions
The Committee received the minute of meeting of the NHS Highland Information Assurance Group held on 20 September 2013. It was noted that a chair had still to be identified for the Group, ideally this should be a clinician experienced in using front line information systems. / Issues identified from the minutes are discussed and escalated as appropriate. / Agreed to alert the Board to the ongoing difficulties in identifying a chair for this Group.
Action: Sarah Wedgwood
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