APPROVED
Minute of Meeting of the NHS Grampian Clinical Governance Committee
held on Friday 29th August 2008 at 9.30am
in the Conference Room,Summerfield House, Eday Road,Aberdeen
Present: / Mr Charles Muir, Non-Executive Board Member (Chairman)Councillor L Bell, Non Executive Board Member
Professor N Haites, Non-Executive Board Member
Mr T Mackie, Non-Executive Board Member (observing)
Professor V Maehle, Non-Executive Board Member
Mr M Scott, Non-Executive Board Member
In Attendance: / Dr J Callender, Clinical Governance Lead - Mental Health Services
Mr R Carey, Chief Executive, NHS Grampian
Dr R Dijkhuizen, Medical Director
Dr R Gatenby, Clinical Governance Lead, Aberdeenshire CHP
Ms H Hardisty, Senior Service Manager (AberdeenCity) attended on behalf of Mr G Poon
Dr S Hamilton, Lead Clinical, Stroke MCNattended for Stroke statistics in the Moray CHP Report (Agenda Item 6.4)
Mrs M Hives, Nurse Manager, Occupational Health Service (observing)
Dr H Howie, Consultant in Public Health Medicine
Mr A Jackson, Legal Advisor
Mr T O’Kelly, Assistant Clinical Director (Acute Sector) attended on behalf of Dr E Robertson
Mr J McKinnon, Infection Control Manager (Agenda Item 5.1)
Mrs L Oldroyd, Nurse Consultant Patient Safety & Experience (shadowing Ms H Robbins)
Mrs F Parley, Clinical Governance Co-ordinator Mental Health & LDS (shadowing Ms H Robbins)
Ms H Robbins, Head of Clinical Governance & Risk Management
Mr E Robertson, Director of Performance Improvement
Mrs E Smith, Nurse Director
Dr P Strachan, Deputy Medical Director
Mrs E Tait, Team Leader (Moray) & Clinical Governance Co-ordinator attended on behalf of Mr M Roos
Mrs N Urquhart, Public Representative
Mrs F Shepherd (Committee Secretary)
The Chairman welcomed Mrs Urquhart, public representative to the Clinical Governance Committee. The Chairman also welcomed those who were attending to shadow and observe.
Item
/Action
1 / APOLOGIESApologies were received fromDr D Cameron,Mr G Poon, Dr E Robertson and Mr M Roos.
2 / MINUTE OF MEETING HELD ON 16th MAY 2008
The Minute of the meeting held on 16th May 2008 was accepted as an accurate record.
3 / MATTERS ARISING
3.1 / Progress Report from Mental Health Services on NHS Grampian – Procedure for Response to Critical Incidents – Reporting and Process
As raised at the previous Clinical Governance Committee meetings Dr Callender was asked to update the Committee on the documented process and procedures associated to risk and suicides in NHS Grampian.
Dr Callender and Mr J Nicol, Team Leader – Mental Health Services & LDS met with Mr Jevan from NHS QIS to agree the process for reporting significant events in NHS Grampian.
3.2 / Progress Report on NHS Grampian MRSA Screening Pilot
As agreed at the previous Clinical Governance Committee on the 16th May 2008 Dr Dijkhuizen would provide a progress report to the Committee. NHS Grampian has started this work and is the only pilot Board to have done so. It was confirmed that the work was funded and so far there had not been any impact on other areas of the service. The project had also been presented as part of the Annual Review. The percentage of patients found to be positive so far is lower than expected. Pre-assessment screening will be commencing shortly.
The Committee agreed that this item will be reported to the Board.
3.3 / Pharmacy Aseptic Audit
The Chief Executive informed the Committee that this issue was reported at the previous Clinical Governance Committee on the 16th May 2008 and was recommended to be discussed at Operational Management Team (OMT). Mr Carey updated the Committee that a detailed report was prepared and discussed at OMT. Funding has been allocated to address the areas of concern.
It was agreed that a copy of the report would be sent to the Clinical Governance Committee. / RC
3.4 / Scottish Ambulance Service support across Board boundaries
Mr Carey agreed to feedback to the Committee on the issue raised in the Moray Sector report at the 16th May 2008 meeting around the Scottish Ambulance Services support across Board boundaries. Mr Carey informed the Committee that Nestrans the transport partnership for AberdeenCity and Aberdeenshire has produced a strategy document on how to address this issue.
Mr Carey suggested that this item is included on the Committee agenda to receive updates.
Mr Carey also mentioned that Mr A Fowlie, General Manager in Moray is in discussion with HiTrans the Highlands and Island transport partnership around transport issues in Moray and Highland. / HR
4 / PATIENT SAFETY
Mrs Smith referred to the report and highlighted the key points from the report:
- The Patient Safety Strategy was approved by the Board on the 5thAugust 2008 and once printed it will be disseminated across NHS Grampian and a copy will be sent to all Clinical Governance Committee members.
- The Scottish Patient Safety Programme are in workstreams; leadership, medicines management, general ward, critical care and perioperative.
- Weekly monitoring of hand hygiene.
- Working with Professor Cuthbertson and PPDUto link the early warning system scoring implementation.
- Leadership walkrounds are established and are now planning to have a walkround once a week in 2009.
- Participating in the University of Aberdeen MSc planning group.
- At the last National learning set event there was twenty six NHS Grampian staff attended and NHS Grampian was asked to present.
- On track with key risk but require to pay particular attention in maintaining staff enthusiasm and momentum.
- Work is progressing well and very fortunate on the support of staff.
Mr Bell congratulated the work that staff have undertaken around the Patient Safety work in Grampian.
Professor Haities mentioned to the Committee around auditing the infection rates in catheters’ to see the impact. Mrs Smith informed that this work is in the early stages and there are not yet any baseline figures. Mr O’Kelly highlighted that presenting data on the run charts encourages staff across the organisation.
Mr Carey agreed to write to the areas across the organisation that achieved 100% compliance to congratulate on progress and work undertaken.
The Committee noted the good progress made around the work of Patient Safety. / ES/HR
RC
5 / NEW BUSINESS
5.1 / Healthcare Associated Infection (HAI)
The Chairman welcomed Mr J McKinnon, Infection Control Manager to report on Healthcare Associated Infection (HAI) in Grampian.
Mr McKinnon presented to the Committee a paper detailing the current HAI priorities including MRSA screening, Hand Hygiene, Clostridium Difficile, QIS standards and Anti-microbial prescribing.
Hand Hygiene – making good progress to reach the national 93% target by November. Posters will be implemented with Aberdeen Royal Infirmary. The HAI team are working with areas to ensure improvement and assist them develop action plans. It was agreed that sectors should report on their progress with implementing Cleanliness Champions in sector reports.
Clostridium Difficile – the Grampian cases are currently being reviewed and a report will follow. This will lead to an action plan. The Committee agreed that NHS Grampian should review its own position against the Vale of Leven report and findings. A number of actions have already commenced such as a review of bed space measurements.
QIS standards - all groups are now set up to ensure compliance with these standards.
Anti-microbial prescribing – this was discussed in conjunction with the Clostridium Difficile section. A range of measures are in place, including working groups, dedicated specialist staff and a Grampian Formulary.
Finally the Committee agreed that HAI should be a standing item on the Clinical Governance Committee agenda and should receive a report on key issues to include surveillance data.
The Committee agreed that this item will be reported to the Board. / Sector
Clinical Leads
5.2 / Clinical Governance & Risk Management Unit Annual Report (2007-2008)
Ms Robbins referred to the report and highlighted the key points from the report:
- Unit work plan was reviewed this year.
- Met with all General Managers to review sector working.
- The benefits of integration are now being realised.
- Resolving the issue around vacancies for the Unit.
The Chief Executive commended Ms Robbins and staff on the 28 unit objectives for 2008-09.
The Committee noted the progress and detail presented in this Annual Report concerning effectiveness of integration of the Clinical Governance & Risk Management Unit.
5.3 / NHS Grampian Clinical Governance Forum Annual Report
Ms Robbins referred to the Clinical Governance Forum Annual Report and informed the Committee that the Clinical Governance Forum was formed at the end of 2006. The role, remit and membership of the Forum states to present an Annual Report to the Clinical Governance Committee with interim reports throughout the year.
Ms Robbins highlighted the key points from the report:
- Members of the Forum were asked to comment on how they felt the Forum was working, to review the usefulness;in view of comments received, the next meeting, has adopted a workshop approach, on the topic - Discharge and Transfer of Patient Information.
Mr Robertson mentioned that the Clinical Governance Forum does not link with the Clinical Governance Committee Role, Remit and Membership.
The Committee noted the progress and detail presented in this Annual Report concerning effectiveness of the Clinical Governance Forum.
5.4 / Neonatal Unit
Dr Strachan referred to the paper prepared by Ms J Fletcher, Assistant General Manager and provided information to the Committee around the current situation in the Neonatal Unit.
There has been an increase in the number of babies requiring this service in Grampian, shortages in consultant staff, junior staff, nursing staff and a high number of sick babies requiring neonatal care.
Dr Strachan informed the Committee that there is an awareness of these issues and a number of steps were being taken in terms of staffing, including appointing additional staff and education programmes to bring staff to a more advanced level thus bringing in an alternative skill mix.
Dr Strachan also mentioned that there had been National reports released which were also being considered. The plans for NHS Grampian reported to the Committee included workforce developments and national discussions.
The Committee was assured that the service and Directors were aware of the issues and concerns, and that action plans were developed.
A further National report is awaited, it was agreed to report back to the Committee any further actions required and progress made once the National report has been considered.
The Committee agreed to note the recommendations as detailed in the report.
The Committee agreed that this item will be reported to the Board.
5.5 / Report on the Generic Record Keeping Pilot Audit
Ms Robbins referred to the report on the Generic Record Keeping Pilot audit and highlighted that this pilot has shown that the audit provides a good indication of the standard of record keeping in nursing notes and highlighted areas of further improvement to develop a generic record keeping framework in NHS Grampian.
The Chief Executive mentioned that he was delighted to see the progress made around the record keeping pilot audit and the importance of being a patient safety issue.
Mr Carey also mentioned the importance of disseminating the findings as detailed in the report (Appendix 1) across NHG Grampian to show areas of improvement, for staff to learn and embed in the patient safety programme.
Ms Robbins suggested and the Committee agreed that sector clinical governance groups look at the quality of record keeping within their own area and report back to the Committee.
The Committee commended the team and all that were involved in this pilot audit.
The Committee noted this report and agreed the recommendations. / Sector Clinical Leads
6 / SECTOR/SERVICE REPORTS
The Committee thanked those concerned for all the hard work that had been put in to producing these reports and commended the Sectors/Service areas on all the Areas of Achievement and good practice that was noted in the reports.
The Committee noted the following reports that have been submitted by the Sectors and Service areas:
6.1 / AberdeenCity
Ms H Hardisty had nothing further to report on what was already written.
Ms Hardisty informed the Committee that there is a lot of work undertaken to address the issues around hand hygiene at the Links Medical Practice.
Professor Maehle referred to item 3e) of this report and asked how long the case study will take. Mrs Smith advised that this usually takes a short time and that all child protection cases are reported on the Datix incident reporting system. Mrs Smith informed the Committee that there will be an update on Child Protection at the next Clinical Governance Committee meeting on the 21st November 2008.
Dr Dijkhuizen referred to Item 3a) of this report around the transfer of children to RACH from Dr Gray’s Hospital and enquired why this is reported in the AberdeenCity report. Mrs Tait mentioned that Moray report these issues to AberdeenCity. Dr Dijkhuizen agreed to contact the clinical lead for Children’s Services, Dr Bissett around this issue.
The Committee felt that this report showed a number of items that required to be reviewed and there was “no update” given. Ms Hardisty agreed to feedback these comments to Aberdeen City CHP.
The Committee asked if the Clinical Governance Forum could address a number of issues around the sector reporting to the Committee; to agree on what is reported; level of risk and the language used. / RD
6.1.1NEQAS testing – NHS Grampian system wide approach
This will be included on the Agenda for the next Clinical Governance Committee meeting.
6.2 / Aberdeenshire
Dr Gatenby brought to the Committee’s attention the areas of concern against the Work Plan under;1a)Occurrence reporting system is still a concern, due to the Datix incident reporting module, not yet implemented in all GP Practices in Aberdeenshire CHP; 1b) Primary Care organisation re-design is a concern around resources to support the transition of services to the CHP, await assurance from the Primary Care Organisation re-design plan to be announced in October 2008.
Dr Gatenby updated the Committee on new areas of concern; 2a) Referral Governance; a practice sent a referral electronically to a mailbox which is no longer active. Immediate action was taken by IM&T to address this issue and to ensure this does not happen again; 2b) Graseby syringe pumps in NHS Grampian are being replaced by McKinley pumps, the CHP seek assurance that all syringe pumps will be replaced in Primary Care and to have the appropriate training.
Dr Strachan clarified that the implementation of the Datix system for incident reporting is progressing toward implementation in all salaried GP Practices in Aberdeenshire CHP.
Dr Strachan explained to the Committee that the Primary Care Organisation (PCO) re-design will be robust and will provide assurance to manage any risks. The PCO re-design project board is being chaired by Mr A Gall, Finance Director.
Dr Gatenby highlighted to the Committee that attached to the Sector report is the Aberdeenshire response to NHS Lothian External Reference Group for Older People’s Service Report as requested by the Clinical Governance Committee. Dr Gatenby informed the Committee that an Action Plan is in place to take forward the recommendations.
6.3 / Acute
Mr O’Kellyupdated the Committee against areas of concern previously reported; 3h) Variation in the availability of patient information leaflets for the prevention and management of Deep Vein Thrombosis (DVT). Support sought fromthe Primary Care Director to streamline across NHS Grampian, this will be in place by October 2008. 3i) Governance of Near Patient Testing equipment scoping exercise is being performed on the equipment used, training undertaken on the use of equipment and guidelines are under development, looked at blood gas and now looking at blood glucose machines and International Normalised Ratio (INR).
6.4 / Moray
Mrs Taitbrought to the Committee’s attention the area of concern against the Work Plan under item 1a) implemented Deep Vein Thrombosis (DVT) guidelines and patient leaflets which were distributed to all patients.
Mr O’Kelly informed the Committee that a business case is being produced for D-Dimer testing to be available at Dr Gray’s Hospital. Mr O’Kelly also mentioned that there is a NHS Grampian wide policy on the management of D-Dimer testing.