APPROVED

Minute of Meeting of the NHS Grampian Clinical Governance Committee

held on Friday 14th May 2010 at 9.30am

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

Present: / Mr L Bell, Non-Executive Board Member
Mr C Muir, Non-Executive Board Member (Chairman)
Professor N Haites, Non-Executive Board Member
Mr T Mackie, Non-Executive Board Member
Professor V Maehle, Non-Executive Board Member
In Attendance: / Dr M Bearn, Clinical Governance Lead, Moray
Dr J Callender, Clinical Governance Lead-Mental Health Services
Dr D Cameron, Chairman, NHS Grampian
Dr R Gatenby, Clinical Lead - Aberdeenshire
Mr A Jackson, Legal Advisor
Mrs S Lonchay, Feedback Advisor (Agenda Items 10.1 & 11 )
Ms J McNicol, Acting Head of Midwifery (observing Agenda Item 4.2.1)
Mr A Pilkington, General Manager
Dr E Robertson, Clinical Lead - Acute Sector
Mr G Poon, Clinical Governance Lead – Aberdeen City CHP
Ms H Robbins, Head of Clinical Governance & Risk Management
Ms J Scott, Clinical Effectiveness Facilitator (observing)
Mrs J Seaton, Technical Services Manager (Agenda Item 5.1 )
Mrs E Smith, Director of Nursing & Quality
Mrs N Urquhart, Public Representative
Ms M Vance, LSA Midwifery Officer (Agenda Item 4.2.1)
Dr L Wilkie, Director of Public Health & Planning
Mrs F Shepherd (Committee Secretary)

The Chairman welcomed and introduced those that were attending for items on the agenda and to those who were observing the Clinical Governance Committee.

The Chairman also mentioned that the strategic risks had been linked to the associated items on the Committee agenda and stressed that the Clinical Governance Committee was the assurance source for these strategic risks.

Item
/
Action
1.  1 / CLOSED SESSION
A separate note was taken for this session.
2.  1 / APOLOGIES
Apologies were received from:
Mr R Carey, Dr R Dijkhuizen, Mrs P Harrison and Mr M Scott.
3.  / MINUTE OF MEETING HELD ON 19th February 2010
The Minute of the meeting held on 19th February 2010 was accepted as an accurate record subject to the below amendment:
Item 10.4 on pages 10 and 11; Include at the end of second paragraph - and commented that he felt the methodology used was not so applicable to Mental Health Services and to include anaesthetic in the last sentence on the third paragraph.
4.  / NHSG CLINICAL GOVERNANCE COMMITTEE – AREAS OF ASSURANCE DEVELOPMENT
4.1 / Clinical Governance Committee Constitution
Ms Robbins referred to the paper and revised Constitution and mentioned that the NHS Grampian Assurance Framework Working Group had undertaken a piece of work to standardise NHS Grampian, Committee Constitution papers to ensure they all contain aspects of risk management. Ms Robbins asked the Committee to consider for approval.
Mrs Smith mentioned that under the paragraph in the Membership section “In Attendance” on page 8; to remove Director of Performance Improvement and to make the necessary changes to other roles as appropriate.
Mrs Smith agreed to enquire out with the meeting whether Dr Strachan in her new role of Chief Operating Officer should attend this meeting or not.
Dr Cameron informed the Committee that the quorum of 50% may not be an issue as there were two newly appointed Non-Executive Board Members commencing in Autumn.
The Committee approved the revised Constitution and noted the changes subject to minor amendments as above. / HR
ES
4.2 / Maternity (Strategic risk 853)
4.2.1 LSMO Midwifery and Supervision Report
The Chairman welcomed Ms M Vance LSA Midwifery Officer who was invited to the Committee to present the Annual Report to the Nursing & Midwifery Council and to provide the Committee with an update on supervisors of midwives in Grampian.
Ms Vance referred to her report and mentioned that the Local Supervising Authority (LSA) report was for the North of Scotland. Ms Vance highlighted the key points from the report:
·  The annual report was risk assessed and the score awarded in September 2009 was 54 (the lower the better) which was an improvement from previous years (85 for 2007-8). This risk was scored as amber.
·  The report identified that NHS Grampian’s ratio of supervisors to midwives had reduced from 2006-7 (36) and 2007-8 (35) to 34 supervisors in 2008-2009, a ratio of 1:12. However eight midwives had a ratio of 1:16 – 1:20. The NMC ratio is 1:15. The reduction over the three years was due mainly to a high proportion of highly trained supervisors retiring and few midwives coming forward for training.
·  Increased number of births in Grampian increasing the clinical workload.
·  The supervisory investigations undertaken by supervisors of midwives in the North of Scotland were notified to the LSAMO for review and agreed recommendations made.
There was a lot of discussion around the concerns regarding issues of encouraging staff to undertake the role of supervisors and to ensure we had sufficient supervisors. The Committee noted that this was a national issue.
Ms Vance informed the Committee that some of the reasons that midwives were not coming forward to undertake this role was due to the training not being undertaken locally and it being challenging to fit the role around clinical workload. Ms Vance advised that in the past there were no incentives to undertake the supervisor role; there was now an enhancement amount of £500.
It was agreed that there was a requirement for this to be discussed out with the meeting and to raise the national issues with key national personnel.
The Committee agreed the recommendations, noted the concerns highlighted and asked for a progress report.
The Committee agreed to report to the Board concerns around the national issues.
/ MV
5.  / QUALITY & SAFETY
5.1 / Datix Occurrence Reporting (Strategic risk 853)
Mrs J Seaton, Technical Services Manager was invited to attend the Clinical Governance Committee meeting to present on the Datix Occurrence Reporting system.
Mrs Seaton referred to the paper prepared by herself and Ms H Robbins, Head of Clinical Governance & Risk Management and highlighted that there were currently over 65,900 incident reports on the Datix system. This report focuses on different aspects of the incident management system including trend data on the top four most commonly reported patient related incident types. Future reports will provide statistical analysis of this data.
Mrs Seaton talked to the report and highlighted the key points as detailed below:
·  A number of initiatives had been discussed at the Datix Project Board to reduce the amount of overdue incidents awaiting review or approval on the Datix system. It was decided to reduce the length of time incidents had in the holding area; this will be reduced from 14 days to 4 days that the incident must be reviewed. It was also agreed to provide a ‘clearing up’ of all low severity incidents to provide the opportunity for a fresh start.
·  The Top 5 reported incidents remain stable.
·  There had been an increase in reporting incidents since the last report to the Committee.
·  A measurement of reporting culture may be determined by the ‘Near Miss’ (No Harm) to ‘Hit’ (Harm) ratio. The aim was to achieve a target of 20% or less (approximately four near misses or incidents with no harm for every one incident that causes harm). Positive progress is being made with achieving this ratio for patient incidents.
·  There had been a positive increase in reporting of medication incidents and food, fluid and nutrition incidents.
Professor Haites asked if the Datix system can identify clusters to highlight specific areas or clinicians. Mrs Seaton responded that managers/key people in the organisation had the capability to run reports to analyse data easily to identify trends.
Dr Robertson highlighted the importance of “policing” the system as the aim was for services to look at their own data and then trends and identify any lessons to be learned.
Mrs Seaton informed the Committee that one of the Clinical Governance & Risk Management Unit Themes was to look at ‘Use of Datix Reports’.
Dr Wilkie mentioned looking at comparisons with other Board areas to identify any trends. Ms Robbins advised of a national benchmarking exercise.
Mrs Seaton advised that there were only 3 boards in Scotland that do not use the Datix system and one or two of them were investigating the possibility of using the Datix system.
There was discussion in the Committee around trends being detected to improve systems then incidents could be reduced.
Professor Haites agreed that now that services were reporting there will be an increase on the incidents reported, there is a requirement to be confident to promote positive work.
Ms Robbins informed the Committee that the Top 5 incidents reported were a challenge and advised the Committee that these were reported in detail at the Risk Management Group meetings but still required further work.
Mr Smith brought to the Committee’s attention that the Global Trigger Tool (GTT) for the Scottish Patient Safety Programme also looks particularly at harm which sits well with Datix.
The Chairman thanked the Committee for their comments and suggestions on future reporting requirements to the Committee.
The Committee noted the report and agreed that the next report to include statistical analysis, trends and identified clusters.
The Committee agreed to provide a report to the Board on positive progress being made with the use of the Datix incident module.
5.2 / Implementing the Quality Strategy Update (Strategic risk 853)
The Committee was provided with an update by Ms Robbins, Head of Clinical Governance & Risk Management on the implementation of the Quality Strategy in NHS Grampian. The Quality Strategy was launched this week. A number of actions had been completed for Stage 1 of the draft Quality Strategy on the implementation process and these actions were detailed in the report.
We now await Stage 2 of the implementation plan and specific actions required. There had been local discussions on how this strategy might be integrated within existing strategic angles in NHS Grampian and how the strategy will fit with the Grampian Health Plan.
Mr Robbins informed the Committee that Mrs Smith had the role of Executive Lead for the Quality Strategy.
Mrs Smith made reference to the challenges around the implementation of the Quality Strategy being integrated into existing practices rather than a separate work stream.
Ms Robbins informed the Committee that there had been a discussion with the Executive team around the Quality Strategy and a quality and safety framework was proposed including incidents. Complaints, patient experience and audit work. This will be explored further.
The Committee noted the recommendations on the report and asked to be kept updated on progress being made. /
HR
6.  / CHILD PROTECTION
Mr Pilkington referred to the report prepared by Ms P Smart, Nurse Consultant Child Protection and updated the Committee on Child Protection:
·  HMIe Inspectors will return to Moray in June to undertake a follow-up review.
·  One outstanding significant case review remains, awaiting outcome from court proceedings.
·  Resources to update the child protection database were being sought. An alternative solution had been investigated and will be embedded by April 2011.
Mr Pilkington informed the Committee that the named Doctor for Child Protection in Moray was leaving in August 2010. This post was to be recruited to. Contingency plans were being developed to enable services to be maintained. The Committee raised concerns around this vacancy not being appointed and asked what contingency plans were put in place after August. Mr Pilkington advised that doctors had been appointed in Aberdeen City and Aberdeenshire and will re-configure to ensure that Moray had cover as well. Mr Pilkington also mentioned and assured the Committee that all paediatricians in their day to day specialist role were trained in child protection but there was a legal requirement to have a named doctor for child protection in each Board area.
The Committee asked to receive a detailed plan of cover arrangements in Moray for the named doctor for Child Protection from August and thereafter.
The Committee noted the report and agreed the recommendations.
/
AP
7.  / HEALTHCARE ASSOCIATED INFECTION UPDATE
In the absence of Mrs Harrison, Mrs Smith presented the paper on Healthcare Associated Infection.
Clostridium difficile: Good progress had been made in the reduction of infection cases recorded in NHS Grampian’s hospitals.
Staphylococcus Aureus Bacteraemia: Although a lot of progress had been made in the incidence of MRSA bacteraemia, NHS Grampian failed to meet the HEAT target for March 2010. Mrs Smith informed the Committee that there were a number of other Board areas that did not meet this HEAT target. An action plan had been produced to monitor to reduce the number of Staphylococcus Aureus Bacteraemia.
Healthcare Environment Inspectorate (HEI) – NHS Grampian Improvement Action Plan:
Mrs Smith referred to NHS Grampian’s Improvement Action Plan which was attached to the HAI report and informed the Committee that since the HEI inspections the plan shows that a lot of actions had been undertaken within the organisation around addressing the recommendations from the inspections. The outstanding actions had been transferred to the Healthcare Associated Infection work plan which was monitored by the Infection Control Committee. Mrs Smith also mentioned that there was good public engagement for hospital cleanliness assessments.
Hand Hygiene compliance: NHS Grampian achieved 97% compliance, the highest compliance rate since the campaign started and was above the Scottish average.
The Committee noted the report and progress being made and agreed that Healthcare Associated Infection will remain as a standing item.
8.  / EXTERNAL REVIEWS UPDATE
Ms Robbins referred to the report and explained that this report was to update the Committee on progress with external reviews as detailed below:
Food, Fluid and Nutritional Care: NHS Grampian had been placed well nationally with the highest score of any of the NHS Board areas. The National Overview on the standards had been attended by the Lead for Food, Fluid and Nutritional Care.
Anesthetics: The final report for NHS Grampian was published in March 2010.
JAG Endoscopy Units: This was the first round of this national UK assessment process and it had been challenging around the methodology and subsequently there was a large number of actions to be addressed. A report will be published after the first three Board areas had been assessed.