DRAFT Minutes of Argyll & Bute CHP

DRAFT Minutes of Argyll & Bute CHP

Clinical Governance and Risk Management Group

Council Chambers, Albany Street, Oban

Monday 25 June 2007 10:30am

Present:

Ms Pat Tyrell, Lead Nurse, Argyll and Bute CHP (Chair)

Ms Fiona Ritchie, General Manager A&B

Mrs Fiona Campbell, Clinical Governance Manager, Argyll and Bute CHP

Mr John Dreghorn, Locality Manager, Mid Argyll, Kintyre and Islay

Mrs Mairi Harvey, Lay Representative

Mr Peter Cartwright, Staff Representative

Mrs Sheila Ogilvie, Senior Infection Control Nurse OLI

Mrs. Hilary Brown, Clinical Services Manager, OLI, (deputising for David Whiteoak)

Via Video conferencing:

Mrs Viv Smith, Locality Manager, Cowal and Bute

Mrs Jean Murray, Senior Infection Control Nurse

Mrs Bobbie Campbell, Senior Infection Control Nurse

Mrs Anne Helstrip, Locality Manager, Helensburgh and Lomond

Mr Lachie Robertson, Patient Focus Manager, NHS Highland (part meeting)

Action
1. / APOLOGIES
Mr. Scott Nicol, Chief Pharmacist;
Dr Viv Shelley, Non – Executive Director;
Mr. Robin Creelman, Lay Representative / Chair Argyll and Bute PPF;
Mr Charlie Gunter, Head of Health and Safety, NHS Highland
2. / MINUTES OF PREVIOUS MEETING
The minutes of the previous meeting on 23 March were accepted as a true record.
3. / MATTERS ARISING
3.1 / Terms of Reference
The minutes of the CHP CG & RM Group will be sent to the NHS Highland Clinical Governance Committee.
Fiona Ritchie stated that she wished to add to the Terms of Reference to make them even more robust and to bring them in to line with other groups and committees that report directly to the CHP Committee. Fiona requested that, if the Group had no objections she would discuss these points with Pat Tyrrell and Fiona Campbell outside the meeting, and this was accepted. The Terms of Reference will be circulated to members for final comments.
Fiona Ritchie explained that since Dr. Erik Jespersen had stood down there was not a Chair for the Group. However, Dr. Mike Hall, based in Campbeltown had been appointed as A&B CHP Clinical Director and would take up the position on 01 July. Fiona Ritchie outlined the intention for Clinical Directors to adopt a system of portfolio management and that that she would be discussing this in more detail with Mike Hall and would be agreeing that either he or one of the other Clinical Directors would be the chair of this Group. The chair will be confirmed at the next meeting of the Group.
Interviews for the CHP AHP Lead will take place early July after which we will be in a position to nominate the appointed person to be the AHP representative to the Group.
The Terms of Reference will be updated and signed off at the next meeting. / Fiona Campbell
Fiona Ritchie
Fiona Campbell
Pat Tyrrell
Fiona Ritchie
Fiona Campbell
3.2 / Cleaning Peer Review Assessment
Robin Creelman has been working with Norman MacLeod and Jim Dempsey to ensure more members of the Patient / Public Forum are involved in the peer review assessment visits.
3.3 / Research and Development
Dr. Catherine Sinclair to be formally invited to the next meeting. / Fiona Campbell
3.4 / Guidelines and Policies
Work is ongoing within NHS Highland in terms of the integration of guidelines and policies. Pat highlighted that it has been recognised that not all policies and guidelines can be integrated due to the different patient pathways within A&B.
Community Pharmacy – Sunday Rota
The Helensburgh and Lomond Community Pharmacy Sunday rota will cease in September. Anne Helstrip is liaising with David Ritchie to issue a newspaper article to be published in July. Viv Smith asked that this be tied in with timescales to cease the Sunday rota in Dunoon. This would enable the same flyers and publicity to be used in both localities. The timescales for Dunoon were envisaged as being late August / early September. / Viv Smith / Anne Helstrip
4. / PATIENT FOCUS
Lachie Robertson had been invited to the meeting to discuss the management and reporting of complaints and patient information.
4.1 / Complaints
Lachie stated that the Complaints Team aims to request investigations within one day of receiving complaints. This is generally achieved, except in cases where the complainant is not the patient, then consent needs to be obtained and this results in some delay.
There have been delays when complaints are received from NHS 24, in some cases it is several days after the complaint being made that it arrives with the Team. Multi agency complaints are also generally more challenging to achieve the target of 20 days.
Lachie stated that the A&B CHP performance for the previous two quarters had been 77% compliance with the 20 days response target. Although there has been fluctuating A&B CHP performance in relation to the target, generally compliance is improving.
Fiona Ritchie stressed that although the target is for 80% compliance with the 20 days response rates, Argyll and Bute would be aiming for nothing less than 100% compliance.
In order to support compliance with the 20 days response times Lachie outlined that, in future an e-mail prompt would be sent to Investigating Officers at 10 days asking if support is required. This e-mail will be copied to Fiona Campbell who will then arrange follow up to offer local support.
Fiona Ritchie requested that Lachie provide an outline of the changes in a documented format so that it could be sent out to members of the Group for comment. Lachie agreed to provide the Group with a draft format for comment by 29th July.
Lachie stated that an Independent Advice Support Service (IASS) for complainants, for NHSH is being negotiated with the Citizens Advice Bureau and would be in place by the end of the year. Lachie stated that furher information about the service would be circulated once arrangements were finalised. This service will also include information giving to patients.
Following a meeting between Fiona Campbell and Lachie the complaints report was being reviewed and Lachie was exploring the possibility of the format previously in place within NHS A&C being adopted. This would enable each locality to identify the performance, status and outcome of its own complaints, to learn from complaints and target actions.
Fiona Ritchie wished a full year’s analysis be included in each report to allow comparison of performance in relation to the 20 day target. She requested that performance for each quarter be shown and a final column to total up the overall percentage compliance.
Fiona Campbell outlined her intention to input the CHP complaints information into Datix to allow local analysis of complaints. Fiona Campbell also reminded Lachie that she had requested individual locality reports to enable discussion to take place at Locality CG & RM meeting. Lachie said he would explore the possibility of providing locality reports.
Fiona Ritchie asked that Pat Tyrrell and Fiona Campbell look at trends and identify follow up actions. It was also agreed that it was important to review individual complaints asking how the complaint could have been prevented and ensuring that lessons are learned across the CHP. James O’Kane Risk / Health and Safety adviser commencing in post on 02 July will have a key role in making the CHP systems for managing complaints more robust and liaising with Lachie and the NHSH Complaints Team.
Lachie outlined the intention to provide complaints training. Complaints investigation had been identified as the priority for training. Training would be targeted at staff involved in complaints investigation: Locality Managers, Clinical Services Managers, Practice Development Nurses and any other staff who are involved. Discussion had taken place at the CHP Best Way Forward Meeting about the need for generic investigation training suitable for both incidents and complaints. Fiona Campbell and Lachie agreed to discuss the training in more detail and to identify dates.
Pat Tyrell asked Locality Managers whether they felt that there was any other support required. The importance of ensuring that a deputy was identified for dealing with complaints was stated. Some localities already provide the Complaints Team with a name of another person to be copied into communications about complaints, for example Personal Assistants / secretaries who would then be responsible for passing on requests to ensure a prompt response. It was acknowledged that there was already a system in place for identifying a deputy for locality managers during periods of annual leave, however this is not always the same person. It was considered important that locality managers inform Lachie about who should be copied in to complaints communications to ensure that complaints are dealt with promptly.
Viv Smith outlined a situation that had arisen within the Cowal and Bute locality when a response had not been sent out prior to a meeting that had been arranged with relatives which made the meeting quite difficult. There had been a five day delay in the Complaints Team sending out the response. The target had not been met as a result of the delay by the Complaints Team.
Fiona Ritchie stated that the draft process flowchart should also include the target for the Complaints Team to get the letter sent out. It was considered that there should be a 24 hour administrative turn around by the Complaints Team at the beginning and end of the process. Lachie agreed that this was the Team’s aim.
Fiona Ritchie asked whether Locality Manager get a copy of the definitive letter when it is sent out. Lachie confirmed that when the letter is sent out by Elaine Mead, the Complaints Team then e-mail a copy of the letter to Locality Managers.
Pat Tyrrell asked Lachie to clarify that the 20 days is from the time that the complaint is received by the Team to the time that the response is sent out to the complainant. Lachie confirmed that this was the case.
It was agreed that the beginning and the end of the process needed to be tightened up to ensure that the response target was met. / Lachie Robertson
Lachie Robertson
Lachie Robertson
Lachie Robertson
Fiona Campbell/
Lachie Robertson
Pat Tyrrell /
Fiona Campbell
Lachie Robertson/
Fiona Campbell
Locality Managers
Lachie Robertson
4.2 / Patient Information
The NHSH Patient Information Policy had been circulated widely within the CHP. The Policy assists staff to develop patient information to a corporate standard and provides guidance, checklists, tools and templates. A flowchart is provided to outline the steps to develop patient information. The first step is to find out if there is an existing NHSH leaflet. If a patient information leaflet is developed it should be sent to Lachie for final checking. Fiona Campbell suggested that if staff were wishing to develop patient information that there should be a forum identified within the CHP for consideration to be given as to whether a leaflet was considered to be a priority for development. It was considered that this could be discussed at Locality CG & RM groups but that a central CHP forum should be identified.
Fiona Campbell apologised that in error she had not sent out the final version of the Policy with the papers for the meeting. The final version had previously been circulated to group members but Fiona agreed to send this again, following the meeting
Lachie outlined that NHSH was exploring the possibility of purchasing a Patient Information Management System (PIMS) to manage the development of patient information. The system is run on an independent web site and would provide a complete database of leaflets accessible through the intranet. Lachie described how the system supports staff through the whole process of patient information development and management. There is a reading age check for leaflets. Running costs for the system are £10,000 per annum. A proposal for purchase is to be presented to the NHSH e-health committee.
Fiona Ritchie, on behalf of the group expressed support for the purchase of the system.
John Dreghorn asked if there was a database of Patient Information within NHS Highland. Lachie stated that while there was a database within Raigmore but otherwise a comprehensive list was not available.
Pat asked that all Locality Managers gather information about locally developed guidelines and that this should be sent to Fiona Campbell who will collate a list on behalf of the CHP and pass on to Lachie.
Fiona Campbell stated that it was important that we didn’t develop local information where there was existing information available. There being several national databases, in use for accessing patient information.
Fiona Campbell felt that it was important that some work was undertaken in relation to improving availability / patient access to information, including display, access and managing stocks of leaflets. Fiona Ritchie suggested that in the first instance Fiona Campbell should contact David Ritchie for support with this.
Mairi Harvey informed the group about the Western Isles HI (Health Information) Kiosks available throughout the Islands Health Board in public libraries, GP surgeries, providing information on local services, drugs, treatments etc. . Lachie confirmed that this service had been provided by PIMs but that this was quite expensive.
Fiona Ritchie hoped that the new NHS Highland website would provide the public/ patients with access to this type of information. There is also opportunity to take forward a similar approach with A&B Council.
Lachie reminded the group that there are NHSH information leaflets available in other languages including Polish, Latvian and Hungarian. Lachie will provide Fiona Campbell with a list of translated leaflets and once this is available it will be circulated so as to raise staff awareness.
Sheila Ogilvie joined the meeting / Fiona Campbell
Fiona Campbell
Locality Managers/
Fiona Campbell
Fiona Campbell
Fiona Campbell
Lachie Robertson/
Fiona Campbell
5. / INCIDENT MANAGEMENT POLICY AND PROCEDURE
The new NHSH IR1 form is being piloted in Tigh na Linne and Ward A LIDGH during the month of June. Training was provided to support the pilot.
Training in the new NHSH Incident Management Policy and Procedures was commencing the week after the meeting and sessions have been scheduled to continue until the end of July. The aim is to make use of existing meetings, wherever possible and to use video conferencing. Training will however be ongoing.
The new system can only be implemented once the IR1 and IR2 forms are finalised, printed and distributed. It was agreed that the situation whereby staff were being trained in a new system which was not finalised and ready to go live was less than ideal. In the meantime the CHP training focuses on making people aware of the proposed changes to the incident management procedures.
Fiona Campbell highlighted the main changes; summarised as:
-Incidents are categorised on the new IR1 by the person reporting the incident
-CSMs are to rate the level of risk associated with each incident
-Depending on the risk rating, this determines the level of response required and whether an IR2 (a form providing additional information, which has not been finalised) needs to be completed
Other points raised about the new procedures included the terms used to describe managers particularly in relation to the response to incidents. It was agreed that it would help to ensure staff clarity, if titles used within the CHP could be included e.g. Locality Manager, Clinical Services Manager. Concern was also expressed that it was unclear as to how the Datix Incident information System could be used to input incidents using the new categories. A decision had not been reached regarding a single Incident Management System for NHS Highland.
Fiona Ritchie asked if Viv Shelley, Chair of NHSH Clinical Governance Committee had been made aware of the highlighted issues. Fiona Campbell confirmed that she had made Viv aware of the challenges at a recent meeting.
Fiona Ritchie asked that Fiona Campbell draft a letter to the Chair of the NHS Clinical Governance Committee, on behalf of the Chair of the CHP CG & RM Group, copied to Elaine Mead, detailing the issues about the new Incident Policies and Procedures. The letter was to be approved by Fiona Ritchie.
Viv Smith asked for confirmation of dates for Cowal and Bute training and Fiona Campbell agreed to provide dates.
Peter Cartwright asked whether the on-call arrangements mentioned in the procedures was in place within the CHP. Fiona Ritchie confirmed that locality managers had written a paper on this and that HR is still looking to resolve this issue on a formal basis but that informal mechanisms are in place. In relation to emergency planning led by Elaine Garman discussions had taken place in relation to major incidents and an arrangement about the wording around the informal arrangements had been agreed. / Fiona Campbell