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MINUTE OF NHS FIFE CLINICAL GOVERNANCE COMMITTEE
HELD ON FRIDAY 14 OCTOBER 2016 AT 2PM
IN THE STAFF CLUB, VHK
Present:
Dr L Bisset, Chair
Ms M Adams, Non Executive Committee Member
Mr S Little, Non Executive Committee Member
Ms J Owens, ACF Representative (and deputy for Helen Paterson)
Mr J Stobbs, Patient Representative
Ms G Tait, APF Representative
In Attendance:
Dr F Elliot, Medical Director NHS Fife
Mr P Hawkins, Chief Executive
Professor S McLean, Director of Acute Services
Mrs E Muir, Clinical Effectiveness Co-ordinator
Dr K Morris, Consultant Microbiologist (for Item 8d)
Mr G Hughes, Observer, Good Governance Institute
Mr M Wood, Observer, Good Governance Institute
Miss C Dziech, Note Taker
MINUTEREF /
ITEM
/ACTION
52/16 /CHAIRPERSON’S WELCOME AND OPENING REMARKS
Dr Bisset welcomed everyone to the meeting in particular George Hughes and Michael Wood from the Good Governance Institute who were attending today as observers as part of the Governance Review.
Dr Bisset also welcomed Janette Owens to the Committee in her new role as ACF Representative and for today representative for Helen Paterson.
Dr Bisset asked that thanks be noted to Dr Cheshire for her valuable contribution to the Committee.
53/16 /DECLARATION OF MEMBERS’ INTERESTS
There were no declarations of interest.
MINUTEREF /
ACTION
54/16 /APOLOGIES FOR ABSENCE
Rona Laing, Alison Rooney, Dr R Cargill, Dr Hannah,Dr S McCallum, Helen Paterson, Michael Kellet,
Helen Woodburn
55/16 / MINUTES OF PREVIOUS MEETING HELD ON 12 AUGUST 2016
The notes of the meeting held on 12 August 2016 were approved with no amendments.
56/16 /MATTERS ARISING
Outstanding Actions from Action ListItem 13
NHS Fife Prevention & Control of Infection Implementation Framework UpdateDiscussed under main agenda Item 8b.
Item 21
NHS Fife Clinical Governance Strategy 2015-2017This item will be considered by the Clinical & Care Governance Committee of the IJB before the final version is considered by the NHSFCGC in December 2016.
Item 27
Management of Adverse Events Improvement PlanDr Elliot advised we are in the process of looking at a more rapid response to SAERs. A further report will follow in December 2016.
/ FMEItem 32
Diabetic PodiatryDr Bisset advised this item was now being taken forward through the IJB and can be removed from the NHSFCGC Action List.
MINUTEREF /
ACTION
56/16 Cont.. /Item 51
Medical Director Reports – Community Physicians Update on Experience & ModelDr Elliot advised she is still trying to track down this report and will circulate in due course.
Post meeting note: this documentation has been circulated. / FMEItem 56
NHS Fife Activity TrackerMrs Adams advised this was an issue which concerned her because of the charity work she undertakes. Mrs Adams advised she had looked into it and was satisfied that there was sufficient information provided for her charity to be consulted. This item can now be closed.
Item 58
Executive Lead Reports & Minutes from Linked CommitteesDr Elliot advised that one of the two health protection nurse specialists usually attends the Infection Control Committee. This item can now be closed.
Item 59
Draft Quality ReportDiscussed under main agenda Item 6.
Item 60
Radiology ProvisionUpdate provided within paper considered under AOCB Minute Ref 63/16 (b).
MINUTEREF /
ACTION
56/16 Cont... /Item 62
Clinical Advisory Panel Annual Report 2015-2016
Dr Elliot advised she had sought comments from a few other Boards (A&A and FV) about how they handle their out of area referrals to see if we could do some benchmarking against them. This exercise had highlighted there were different issues for each Board with no standardisation so it would therefore not be possible to undertake any benchmarking. This Item was closed. / FMEItem 63
Novel ProceduresUpdate provided considered under AOCB Minute Ref 63/16 (a).
Item 64
MRSADiscussed under main agenda Item 8d.
Item 65
Paediatric Drug TrolleyDiscussed under main agenda Item 8c.
57/16 /MEDICAL / NURSE DIRECTOR REPORTS
Draft Quality Report
Dr Elliot described the further iteration of the report in which the comments from the last meeting were incorporated, particularly to include more narrative. Dr Elliot confirmed Ms Paterson had contributed to the changes.
Professor McLean and MKellet indicated the changes were not at odds with the direction of travel in the ASD and HSCP.
Dr Elliot also indicated that the report will develop further as the Integrated Performance Report (IPR) develops and will be incorporated into the IPR.
Dr Bisset asked if the correct topics are covered. Mr Little suggested there was scope for further details to be added for person centred care. Ms Owens responded to confirm that more detail will be included from the Patient Opinion feedback and other more direct patient experience data. Dr Bisset asked if there was scope for the PFPI Group to feed into the report.
Ms Owens commented that the Participation Standard and public engagement strategy will also influence the report.
Dr Elliot indicated there was an opportunity to formalise sampling to improve the patient feedback data included.
Mrs Adams noted that the report only included feedback about acute services. Dr Elliot responded that primary care feedback goes direct to the independent contractors and community feedback is picked up through the IJB systems and processes.
Mr Hawkins said that the NHS needs to change and learn from industry where feedback is actively sought in real time. Dr Bisset felt we need more measurable outcomes included in the report. Mr Hawkins responded that we will require an action plan with measurable milestones to set out how this will improve further but it needs to be part of the IPR. Dr Bisset commented it was heading in the right direction and asked the Committee to confirm this could replace the HealthCheck document. There was agreement with this.
Dr Elliot replied to say the report will need to be signed off by EDG before that can happen.
58/16 /CLINICAL STRATEGY
Dr Elliot advised following a twelve week engagement process the Clinical Strategy is now being finalised and will be taken to the NHS Fife Board on 25 October 2016 for final approval before publication and implementation.
The public and staff engagement process has not identified any significant issues with the key recommendations of the draft Clinical Strategy. The recommendations therefore remain unchanged.
It was noted there had been a disappointing response to community engagement. Dr Elliot advised no new issues had had been picked up from either community engagement or via the online Survey Monkey.
Mr Little commented it was fantastic to have a good strategy as a “go back to” document but did question how do we communicate to take the strategy forward. Dr Elliot agreed this is a good strategy and articulated well with issues such as Realistic Medicine. The Plan, once the Board approves the strategy, is to go back out to engage with clinicians and staff side with next steps to prioritise the recommendation for implementation. There will also be focused consultation with the public on any service redesign that will follow on from this. Work would also continue on key recommendations to take forward for the future and be communicated to staff and the public.
Dr Bisset reiterated this was an exemplary document.
The Committee noted:
- Public engagement process and outcomes
- The current status of the Clinical Strategy.
59/16 /
GOVERNANCE ITEMS
59/16 /a)Corporate Risk 520 (Child Protection)
The Committee noted the contents of the report.
59/16Cont... /
The Committee noted the previous decision reached (January 2015) to retain this risk on the Corporate Risk Register due to the number of Significant Case Reviews being undertaken in Fife. This work in ongoing, therefore the Risk remains on the Corporate Register at this time.
The NHS Fife Clinical Governance Committee:
- Noted the risks identified as the Committee’s responsibility
- Endorsed the overall approach to the management of risk as described.
59/16 /
b)NHS Fife Prevention & Control of Infection Implementation Framework
c/forward from August 2016
This paper was presented to the Committee to consider and agree / approve the content.
Mr Little questioned with the number of groups / Committees reporting in to the Infection Control Committee does it not diffuse responsibility? Dr Elliot said Infection Control was everyone’s business andwas not something that could be invested in just one committee. The Infection Control Committee represents all staff groups who are able to advise if the best systems and processes are in place across the NHS organisation.
Dr Bisset advised he had previously raised the issue of the inconsistencies of attendance and quorum by all these groups but accepted if this was required then he was content. Dr Elliot said there was a multi dimensional problem and several inter related groups are required.
The Committee noted the report was issued in October 2015 and it agreed the membership issues should be taken back to the Infection Control Manager to note when preparing the next report.
/ JO59/16 /
c)Medication Safety Action Plan
The purpose of this report is to provide the NHSFCGC with assurance that the Action Plan developed following a significant adverse event in Paediatrics was now complete.
Dr Bisset said this was a comprehensive Action Plan and reassuring to note all actions were completed. Dr Bisset asked for an update to be brought to the February 2017 meeting of the NHSFCGC.
/ HP59/16 /
d)SABs
All Health Boards have been given a target to reduce S aureus bacteraemia (SAB) to a rate of 0.24 AOBD by 31 March 2017.
The Committee is asked to consider and agree / approve the content of the report MRSA Bacteraemia in NHS Fife produced by Dr Keith Morris and Janette Owens.
Dr Morris asked the Committee to note the paper tabled for the meeting had been prepared from information provided by Health Protection Scotland which was not in the public domain and therefore not for discussion outwith the Committee.
The Committee noted the contents of Dr Morris’s report and the confidential nature of the data provided within it.
Professor McLean advised the Committee Dr Morris had led this work and changes and his commitment was greatly appreciated. Professor McLean also advised Dr Morris attends the safety huddle every two weeks to give an update on infection prevention to ensure engagement in Fife and this was welcomed. He thanked Dr Morris.
59/16Cont... /
Dr Bisset also thanked Dr Morris for his update and his reassurance to the Committee. Dr Bisset suggested it would be helpful to have a further update and would leave it to Dr Elliot and Professor McLean to liaise with Dr Morris to arrange when this would come back to the Committee.
/ FME/SMcL
59/16 /
e)NHS Fife 2016/2017 Winter Plan
Professor McLean advised the report being presented to the Committee requires no action at this stage. The report will go to the Board in October 2016 and then to F&R in November 2016.
Professor McLean highlighted In accordance with Scottish Government Guidance DL (2016) 18 NHS Fife is required to lodge draft winter plans on local winter planning arrangements by the end of August and final plans by the end of October 2016. A continued focus on integration, improving delayed discharges underpinned by the six essential actions is required.
In late March 2016, Fife reviewed its performance against the 2015/2016 Winter Plan. That session culminated in the formation of the 2016/2017 ‘Big Plan’. The report being considered is the draft Winter Plan for 2016/2017 which encompasses these clinician-led changes which will improve unscheduled care over the winter months and become embedded into daily practice.Dr Bisset said this was an excellent piece of work and flows well from the previous version.
Dr Elliot advised she had attended the GP Sub Committee to discuss the new referral pathways document developed by Dr McKenna. The GPSC would like this information to go to Practice Managers as well.
59/16 Cont... /Mr Hawkins raised that SAS had received Cabinet Secretary approval to review the status of 999 calls. We need to be mindful that this change may take place near the Christmas holiday period and could add to service pressures. Dr Bisset asked if there would be formal consultation on this. Mr Hawkins advised work would start with GPs. Dr Bisset highlighted it was important the Board was actively engaged in this consultation.
60/16 /ANNUAL REPORTS
60/16 / a)SPSP – PC ReportThe Scottish Patient Safety Programme in Primary Care (SPSP-PC) commenced in March 2013 and the report presented covers the period April 2014 to March 2015.
The programme has three elements: a safety climate survey; a trigger tool review (enable harm to be identified in case records); and a care bundle. The care bundle chosen was Medicines Reconciliation. The first two elements were part of the Quality Outcomes Framework and element three was part of a Local Enhanced Service. Work also continued on the warfarin safety bundle that had been introduced in 2013.
All 58 practices participated in the programme and 55 of them completed all three elements. The paper demonstrates the positive changes that were made by practices as a result of this safety work.
60/16 Cont... / Dr Elliot advised the Committee to note the timing of the report (2014-15) and advised she was chasing the 2015-2016 report. Dr Elliot also confirmed work for the 2015-2016 report continues along the previous themes and key elements.
The Committee noted the report and its content.
61/16 / EXECUTIVE LEAD REPORTS AND MINUTES FROM LINKED COMMITTEES
Dr Bisset advised all items under this section would be taken without unless any particular issues were raised.
61/16 /
a)ASD CGC
20 July 201661/16 /
b)Information Governance Group
11 August 201661/16 /
c)Fife Area Drugs & Therapeutics Committee
17 August 2016
Dr Elliot advised the Final ToR for Fife Formulary Committee had been discussed and agreed at EDG that a further piece of work and change was required. The revised ToR would be considered again at the December 2016 meeting of the NHSFCGC.
/ FME61/16 / d)Patient Focus Public Involvement
3 August 2016 rescheduled to 9 September 2016
61/16 / e)IJB
4 August 2016
62/16 / ITEMS FOR NOTING
62/16 /
a)NHS Fife Activity Tracker
Noted with no comments.
62/16 /b)NHS Fife Clinical Governance Committee Workplan 2016/17
Noted with no comments.
62/16 /c)Diabetes 12 Quality Improvement & Outcome Measures Reporting Guidance
Noted with no comments.63/16 / AOCB
63/16 / a)Novel Procedures
Item 63 on Action List
Dr Elliot / Mr Hawkins advised The Flow Chart for Introduction of Novel Procedures tabled to the Committee would be taken to EDG for further discussion and brought back to this Committee in December 2016. / FME
63/16 / b)Clinical Risks
The Chair of the Board requested a discussion at the Board about the top clinical issues that have been considered by the Clinical Governance Committee. This report covers the last six months of meetings and highlights the following key clinical risks:
Radiology Services
MRSA
Falls
Tissue Viability
Clinical Workforce
The Committee noted the identified issues.
The Committee noted that the EDG has commissioned a comprehensive review of the risk register to define the top corporate risks which will underpin the developing Board Assurance Framework.
63/16 /c)Quality Improvement Workshop
Mr Little advised he had recently attended the QI Workshop and asked if there was an overview through NHSFCGC of how QI comes together and who and how it is taken forward. Professor McLean advised work was underway within the organisation to make QI more systematic. The QI team is now an integral part of the IMPACT team.
63/16 /d)Ransomware
Mr Little advised he had recently read an article in the Independent that 50% of Scottish Boards were subject to Ransomware and should the Committee be made aware of the risks. Dr Elliot advised there was software in place to identify attacks on our system. eHealth is also very conscious this risk has increased and policies are in place to deal with these issues. Dr Elliot advised Mr Little should speak to Lesly Donovan, eHealth Manager, outwith the Committee for a further update.
64/16 /DATE OF FUTURE MEETINGS
14 December 2016 at 2pm in Meeting Room 2 within Ward 6, Phase 1 VHK
15 February 2017 at 9.30am in Meeting Room 2 within Ward 6, Phase 1 VHK
Y:\Governance\Formal Meetings\Groups and Committees\Board\2016\December\Item 13a - Mins Clinical Governance Committee 14 October 2016 unconfirmed.docx / Issue: V1 / Date: October 2016Originator: Catriona Dziech / Page 1 of 13