APPROVED

Minute of Meeting of the NHS Grampian Clinical Governance Committee

held on Friday 27thMay 2011 at 9.30am

in the Conference Room, Summerfield House, Eday Road, Aberdeen

Present: / Mr C Muir, Non-Executive Board Member (Chairman)
Mr L Bell, Non-Executive Board Member
Professor N Haites, Non-Executive Board Member
Mr T Mackie, Non-Executive Board Member
Professor V Maehle, Non-Executive Board Member
Mr M Scott, Non-Executive Board Member
In Attendance: / Mr B Archibald, Service Planning Lead (Agenda Item 4.1)
Dr J Callender, Clinical Governance Lead-Mental Health Services
Dr D Cameron, Chairman, NHS Grampian
Dr S Cole,Clinical Governance Lead,(Acute) Moray CHP
Dr R Dijkhuizen, Medical Director
Mr S Dustan, General Manager Aberdeenshire CHP (Agenda Item 4.2)
Dr J Fitton, Clinical Governance Lead - Aberdeenshire
Mrs P Harrison, Infection Control Manager
Dr J Hogg, Clinical Governance Lead, (Primary Care) Moray CHP
Mr T O’Kelly, representing Dr E Robertson, Clinical Governance Lead, Acute Sector
Ms H Kelman, Clinical Governance Lead, Aberdeen City CHP
Dr M Thakur, PMS Clinical Liaison(observing)
Mrs E Smith, Director ofNursing & Quality
Mrs E Tait, Team Leader/Clinical Governance Co-ordinator
Mrs N Urquhart, Public Representative
Ms S Webb, Clinical Governance Lead, Public Health & Planning
Ms K Dickson, Administrator (shadowing Mrs Shepherd)
Mrs F Shepherd (Committee Secretary)

The Chairman welcomed everyone to the Committee and introduced those who were attending the Committee for agenda items, to observe and shadow.

Item
/
Action
  1. 1
/ APOLOGIES
Apologies were received from:Mr R Carey, Mr A Pilkington, Dr E Robertson and Dr L Wilkie.
MINUTE OF MEETING HELD ON 25thFEBRUARY 2011
The Chairman referred to the minute of the meeting dated 25th February 2011 and mentioned that this meeting was not quorate. It was agreed to go ahead with the discussion of the meeting with no decisions taken. The Chairman asked members if they were happy to approve the discussion minuted at this meeting.
The members approved the minute of the meeting held on 25th February 2011.
  1. 1
/ MATTERS ARISING
3.1 / Medical re-validation Process
After a discussion at the previous Committee meeting, the Committee asked to receive a report on the systems and processes in place around the re-validation of medical staff in NHS Grampian.
Providingthe Committee with a verbal update on medical appraisal, Dr Dijkhuizen was very confident that NHS Grampian would not foresee any issues around this process.
Dr Dijkhuizen went on to provide some background information on medical re-validation, this process was due to commence in April 2012 and all re-validations were to be completed by April 2013 with a formal sign off by 2018.
Dr Dijkhuizen mentioned that a significant amount of work is being undertaken at a national and local level in preparation for the re-validation as detailed below:
  • Appraisal leads in NHS Grampian were appointed.
  • First stock of who should be appraised – all GPs on the Performers list.
  • 100% appraisalsin Primary Care is quality assured by the training organisation NES. To prepare for revalidation, appraisers will be trained by NES in workshop sessions.
  • Around 40% of medical staff in Secondary Care had already commenced a similar process.
Mr Bell asked the question: what would happen if the re-validation process failed. Dr Dijkhuizen responded that this was unlikely to happen. Dr Dijkhuizen highlighted that it was of interest for medical staff to be re-validated to continue to practice. The appraisers will be trained to deal with any issues arising prior to the appraisal date.
Professor Haites made reference to the new retirement age for clinicians and asked the Committeefor their thoughts around performance. Dr Dijkhuizen mentioned that the retirement age being introduced is 65 or over. To quality assure,clinicians in this age group, will beappraisedannually.
A question was raised around clinicians in management roles. Dr Dijkhuizen clarified those clinicians that were in management roles will beappraisedboth clinically and for their management responsibilities.
NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE DEVELOPMENT
4.1 / NHS Grampian Dental Plan 2008-12 Risk Assessment(Strategic risk 853 & 856)
The Chairman welcomed Mr B Archibald, Service Planning Lead for Oral Health and Dentistry to the Committee.
Mr Archibald presented to the Committee the update report on the NHS Grampian Dental Plan which highlighted the physical planning, clinical governance and risks associated with NHS Grampian Dental Plan.
Mr Archibald informed the Committee that initial risk assessments had been undertaken through; dental practice inspections, premises survey, a decontamination survey and ad hoc visits/planning support/grant application system. Mr Archibald brought to the Committee’s attention a number of concerns, the main one being that there were a small number of dental practices that were not meeting the decontamination standards. Mr Archibald informed the Committee that actions will be progressed with each of the practices on an individual assessment basis.
Mr Archibald referred to his report and highlighted the main points as below:
  • The volume of dental patients seen in Primary Care Dental Services in Grampian, three main areas were the; high volume of dental equipment used for dental visits required to be processed through a decontamination system; the complex procedures and radiographic examinations. This is being managed through dental inspections and close working with the CHPs.
  • It is estimated that there will be an increase of dentists this year in Grampian. To attract new dentists to stay in Grampian the development of premises is being looked at.
  • Risks identified show that NHS Grampian does not have the required number of dental vocational trainers and trainees. Work is progressing to address this risk to achieve the Dental Plan requirement.
  • Due to not meeting special needs and access requirements, 5 dental community premises in secondary schools will have to be closed. Plans were in place to replace 3 of these by using the capital made available for dental premises by a benefactor.
  • There were no major risks relating to salaried dental premises.
Mr Archibald advised the Committee that NHS Grampian had received 5.4 million for the primary care dental investment.
The Chairman asked for questions. The Chairman also commented that he felt that the risks detailed in the report should be graded by severity and be signed off by the responsible manager to evidence being addressed.Mr Archibald advised an update on the Dental Action Plan is due tobe presented to the Board in August andwill have risk appropriately graded.
Discussion ensued in the Committee around individual dental surgeries and the lack of clarity as to who is responsible or liable if surgeries arenot compliant with the decontamination guidance.
Further questions were raised around the government funding allocated to dentistry.
The Chairman concluded that further clarity and assurance was required for the Committee around a number of issues, and asked that these issues were addressed at a management level. A further report would be presented at a Clinical Governance Committee to provide the Committee with assurance that these issues were progressing.
The Committee noted the report and agreed to receive a further report at a future meeting.
The Chairman thanked Mr Archibald for attending the Committee following which he left the meeting.
The Committee agreed that this item was to be reported to the Board. / BA
BA
4.2 / Prison Health Services(Strategic risk 853)
Mr Dustan, General Manager Aberdeenshire CHP was asked to attend the Clinical Governance Committee to provide a report on Prison Health Services, Clinical Governance arrangements and to report on the plans in place for the transfer of Health Services to NHS Grampian.
Mr Dustan referred to the report and Operational Plan prepared by Mr McEwan, Service Planning Lead (Prison Health) and highlighted the two main principles:1. The transfer of responsibility for prison healthcare from Scottish Prisons to NHS Grampian. 2. Integrating of the 2 prisonsHMP Aberdeen and Peterhead to be replaced by a new build by 2014.
Mr Dustan assured the Committee structures were in place to develop the plan for transfer. Various groups had convened with representation from Heads of Services from NHS Grampian and Scottish Prison Service to progress the detailed arrangementsas detailed on page 11 of the Operational Plan.
Mr Dustan highlighted some key points from the report as detailed below:
  • The audit governance tool kit will be used to identify any clinical governance issues.
  • The arrangements for dealing with healthcare related complaints and FOI requests were to be agreed.
  • Work is being carried out nationally with regards to information sharing/transfers of data with regards to sharing information and accessing records.
Dr Fitton referred to the proposed model for the provision of medical services including OOHcover and the OOH contact time,GPs may be less willing. Mr Dustan mentioned that after consideration the agreed and preferred option was for NHS Grampian to contract with a local General Practice for this service.
Dr Cameron made reference to this being the first time the Clinical Governance Committee had received a report on this item and suggested that it should also be presented to other Committees,e.g. the Staff Governance and the Audit Committee.
Mr Dustan highlighted that the quality of service provided will improve. However, the provision of primary care dental services is not adequate and is being reviewed.
Mrs Tait referred to one of the key risks in the report relating to the transfer of funding for the provision of the service and made reference to the clarification sought around this risk. Dr Cameron also cautioned managers involved in this process to ensure that the (as yet undisclosed) amount of funding allocated to NHS Grampian from the Scottish Prison Service covered all aspects of care required to look after the health of prisoners.
Mrs Smith made the suggestion that this item could be a topic at a future Board Seminar.
The Committee noted the report and acknowledged the significant amount of work being managed by the various stakeholders within NHS Grampian. It was also noted that the lack of clarity around the transfer of funding makes planning this project more complex. Further key risks were around technology and HR issues to bring Scottish Prison Health Care staff training in line with NHSGrampian.
The Committee acknowledged the risks and wasassured that plans were in place to develop a Prison Health sub group reporting through Aberdeenshire CHP thereafter to the Clinical Governance Committee.
The Chairman thanked Mr Dustan for attending the Committee following which he left the meeting.
4.3 / Introduction of NHS Scotland Integrated Adult Policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
It was agreed to defer this agenda item to the 26th August 2011 meeting as Dr Cooper was not available to attend.
4.4 / Review of Sector Clinical Governance Arrangements Report
The Chairman talked to the report written by Mrs Tait, Team Leader & Clinical Governance Co-ordinator which was prepared on behalf of the review team’ the Clinical Governance Committee Chairman, Director of Nursing & Quality and Head of Clinical Governance & Risk Management.
The Chairman referred to the report and provided background information on the reviews of the Sector Clinical Governance Groups. Reviews had been undertaken over the past 4 years; the initial reviews of the groups were in 2007/08 and thereafter reviewed annually to provide assurance on the effectiveness of the governance processes. Following the review a written report had been provided to feedback to the groups to highlight the good practice being undertaken, any suggestions, learning points and ideas for improvement.
Mrs Smith commented that this is a two way process and made an observation that the groups were well chaired and that relevant people had been invited to talk on specific items.
Mr Muir referred to the NHS Quality Improvement Scotland Clinical Governance & Risk Management peer review in 2009 where it was commented by the review team that this was a good example of a clinical governance process.
The Committee agreed to continue to support the reviews of the Sector Clinical Governance groups in NHS Grampian.
PERSON CENTRED(Strategic risk 853):
5.1 / Joint Incident, Feedback and Claims Report
The Chairman welcomed Mrs Oldroyd, Nurse Consultant Patient Safety and Experience and Mrs Seaton, Technical Services Manager to the Committee to present their paper on Joint Incident, Feedback and Claims.
Mrs Oldroyd mentioned to the Committee that this joint report is presented in this new format, to provide the data and information on incidents, complaints and claims to assure the Committee that NHS Grampian were learning from experience.
Mrs Oldroyd referred to the report and highlighted some of the key points as detailed below:
  • All incidents, feedback and claims were now recorded on the Datix system which allows seeing the links between them to highlight issues to address and learn.
  • Since 2005 there had been seven incidents that were also a complaint and a claim. To demonstrate by sharing some patient stories two stories were included under Case Studies 1 to show what happened, action taken and sharing or not sharing the learning in NHS Grampian.
  • Mrs Oldroyd referred to the case studies and mentioned that case A learning was recorded and action taken. The second case B was a patient safety incident.
  • To look at the Top five incidents, complaints and claims from 1st January 2009–31st March. Top1 for incidents: Accident (slips, trips, falls, exposure to blood and body fluids or other hazards); the Top 1 for complaints:treatment and the Top 1 for claims; Accidents.
Mrs Seaton then went on to talk to the report around the reporting on the Datix system that there had been a significant increase in reporting since the inclusion of a Datix icon on the intranet.
Mrs Seaton highlighted the key points from the report as detailed below:
  • Measurement of reporting culture on page 5 would be good to achieve a target of 20% or less. We were to date sitting at 29% for ALL incidents and for Patient related incidents the culture result to date is 24%, a slight increase from 2010 due to the Obstetrics service now reporting on the system.
  • Work is constant to improve the coding and to create incident reporting forms for Anaesthetics in Dr Gray’s Hospital and Gynaecology and Radiology in Aberdeen Royal Infirmary.
The Acute sector Datix group is working well with presentations at each monthly meeting by a member on how they use and learn from the information from Datix in their area.
Mrs Oldroyd moved on to talk about Case studies 2 – Incidents to complaints and mentioned that the learning from Case C was shared at the ward team meeting. Case C led to an investigation and recommendations to improve the service.
Feedback received from 1st April 2009–31st March 2011 suggests there is a slight upward trend in the amount of feedback received.
Mrs Oldroyd referred to Figure 4 on page 8 of the report and highlighted to the Committee the feedback received by the sectors over the period 1st October – 31st March 2011.
In the6 month period there were 684 formal and 40 informal complaints received.
Mrs Seaton referred to the Claims section on the report and highlighted Figure 6 on page 14 which shows the number and type of claims received into the organisation since April 2009.Thesedetail an increase in the number of claims received.
Mrs Seaton mentioned that as a result of incidents, complaints or claims, service improvements were identified some of which were included in the report under Table 13 on page 18.
Mrs Oldroyd informed the Committee that the Clinical Effectiveness Team will be looking at the compliments that the organisation receive to identify themes.
Mr O’Kelly referred to the Case study 2D around the medication incident and asked if data could be provided on the amount of episodes that had occurred.
Ms Seaton made reference to a piece of work being undertaken around this issue with Health Intelligence.
Dr Dijkhuizen commended the report illustrating the connections with complaints, claims and incidents. Dr Dikhuizen intimated two points:
1.Very interesting to look at the links with incidents, complaints and claims.
2.Clinicians receiving complaints and compliments would like to see feedback to the individuals for the invitation to discuss at yearly appraisals.
Mrs Oldroyd commented that the Feedback team have tried to identify from complaints what may have actually been a specific incident. In these casesClinical Governance Co-ordinatorscan go back to the Sector and encourage the clinical staff to respectively record this as an incident. This would enable early learning from incidents and may over time reduce complaints. Clinical Governance Coordinators may be in a position to support managers to complete investigations and monitor improvements.
Dr Fitton commented that the Feedback for Aberdeenshire is timely in reaching management. Dr Fitton suggested that she would make improvements by working with the Feedback Team.