NHS GRAMPIAN
CLINICAL GOVERNANCE COMMITTEE REPORT
Introduction
The following key agenda items were discussed at the NHSGrampian Clinical Governance Committee meeting on Friday 30th November2012 and it was agreed that they should be reported to the Grampian NHS Board.
Strategic context
The Clinical Governance Committee acknowledged it had a role in seeking assurance for the clinical risks extracted from the Strategic Risk Register, as per its remit below:
Clinical Governance Committee.This Committee has the responsibility, on behalf of the Grampian NHS Board, for reviewing and challenging risks that are on the strategic or corporate risk registers in respect of clinical governance issues. It should be satisfied that all clinical risks have been appropriately identified and that the control measures that are in place and that are planned to be in place are adequate to manage the risk identified.
The relevant clinical risks include:
- 853 – Patient Safety is compromised and is not evidenced in practice
- 586 – Future services are not developed in partnership with local authorities, third sector and independent contractors and the communities
Discussion
- Update on Implementing Healthcare Improvement Scotland Stroke Care Standards.
This relates to strategic risk 853 Patient Safety
The Committee was updated onNHS QIS (Quality Improvement Scotland - now Healthcare Improvement Scotland) Stroke Care Standards, the HEAT target for Stroke Unit admissions and the Better Heart Disease and Stroke rehabilitation provision.Various issues in relation to stroke care for patients were highlighted:
- Although NHS Grampian isachieving the 2012 HEAT target of 80% of patients admitted to anAcute Stroke Unit (ASU) on the day of admission or day following presentation, this target willincrease to 90% in April 2013.
- Challenges regarding patient flowthroughout the patient pathway.
- Stroke audit data at Dr Gray’s Hospitalwas incomplete.
- Dr Gray’s Hospital does not have an integrated Stroke Unit butworkstoStroke Unit guidelines.
A named consultant to take responsibility for Stroke Services in Moray had been identifiedand a data collector appointed to support the consistent activity reporting of audit data locally and nationally for Dr Gray’s Hospital.Various initiatives were allowing social and health services to shift the balance of care, allowing patients to move very quickly from acute care to their familiar care settings.
The Clinical Governance Committee noted the report and initiatives in place to improve the service and asked for anupdate report in 6 months.
2. Mortality and Morbidity
This relates to strategic risk 853 Patient Safety
The Committee was provided with an update on mortality and morbidity in NHS Grampian The Committee wasreminded that the aim of the Scottish Patient Safety Programme (SPSP) was to reduce mortality and adverse events in acute hospitals in Scotland. The Committee heard that the Scottish Government had announced phase two of the SPSP, which aimsto extend the reduction in hospital mortality from 15% to 20% by December 2015. The Committee noted that ARI and Dr Gray’s Hospital had demonstrated progress towardsthe Hospital Standardised Mortality Ratio (HSMR)target over time.
The Committee noted the report and agreed the recommendations to approve and support the actions detailed.
3. Health Care Associated Infection Report
This relates to strategic risk 853 Patient Safety
The Committee was updated on InfectionPrevention and Control. It heard thataudit results around hand hygiene, cleaning and estate monitoring had shown that compliance across NHS Grampianhad remained above the national target. The Committee was advised of support provided by the Infection Prevention Team to care homes, nurseries and other teams dealing with norovirus. An update was given on progress following the Healthcare Environment Inspectorate (HEI) unannounced inspection at Aberdeen Royal Infirmary on 7-8 August 2012.
The Clinical Governance Committee noted the report and initiatives in place to improve the service and will receive further updates at future meetings.
4. Annual Report to the Nursing & Midwifery Council (NMC) 2011-2012, Local Supervising Authority (LSA)
This relates to strategic risk 853 Patient Safety
The Committee was presented with the Annual Report to the Nursing & Midwifery Council on Supervisors of Midwives in NHS Grampian. The Committee was concerned that the uptake for training for Supervisors of Midwives was not as good as expected and discussed the risk to NHS Grampian. The Committee heard of various initiatives and good practice to encourage more midwives to come forward for training, to enable NHS Grampian to maintain the recommended NMC ratio of 1 supervisor to 15 midwives.
The Committee heard that three investigations had been undertaken by Supervisors of Midwives in Grampian in the reporting year and none of these had required referral to the NMC and that there had been no maternal deaths reported to the LSA in the reporting period.
Recommendations
The Board is asked to note this report from the Clinical Governance Committee and acknowledge that the Committee’s roles and responsibilities are being met
Charles Muir
Clinical Governance Committee Chairman
January 2013