Present:Miss J Fraser, Non Executive Director, SSU

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/
MINUTE of MEETING of the
SSU GOVERNANCE COMMITTEE
4th Floor Meeting Room, RaigmoreHospital /

12 July 2006 – 3.00 pm

Mr S Denholm, Clinical Director, SSU

Ms C Stewart, Partnership Forum Representative

Ms S Eddie, Unit General Manager

Mr A Ward, DGM, Woman & Child Health

Mr R Ward, DGM, Clinical Services & Support

Mrs L McClurg, Nurse Manager, Surgical & Anaesthetics Ms D Buchan, DGM, Surgical & Anaesthetics

Mr Q Cox, Clinical Director, Surgical & Anaesthetics

Mr N Hobson, Associate Director of Nursing

Mr S Loch, Nurse Manager, Woman & Child Health

Ms K Hogan, SSU Accountant

Dr C Lush, Clinical Director, Clinical Services & Support

Ms I McGauran, Nurse Manager, Medical

Mr D MacRae, Hotel Services Manager

Dr D A R Lees, Clinical Director, Woman & Child Health

Apologies:Dr K Oates, Consultant, Public Health

Ms R Magee, Health & Safety Adviser

Mrs M Smith, Information Manager, E-Health

Ms M Morrison, Clinical Governance & Risk Manager

Ms L Kirkland, DGM, Medical

Ms P Courcha, Non Executive Director

Mr P Mutton, Lead Pharmacist - SSU

Ms F Matthewson, Planning Manager

Ms C Morrison, Personnel Adviser

Ms C Walker, Personnel Adviser

Dr R Harvey Clinical Director, Medical

In attendanceMr G Smith, Highland HealthVOICES Network Member

Ms J Thompson, Highland HealthVOICES Network

Ms C Steer, Health Promotion

Mr R Henderson, Public Health

Ms K Boocock, Paediatric Physiotherapy (shadowing Stephen Loch)

1 / Welcome & Introductions
Miss Fraser welcomed Mr Smith to the meeting and advised members that Mr Smith was the Highland HealthVOICES Network member appointed to SSU. Miss Fraser encouraged Mr Smith to raise any points he may have at the meeting, but also to raise any issues directly with Ms Eddie or herself if preferred, outwith the meeting.
She also welcomed Ms Thompson, to discuss HHVN, Ms Steer to discuss progress in relation to the Tobacco Strategy Action Plan and Mr Henderson to discuss SSU plans in relation to the NHS Highland Pandemic Flu Plan.
The issue of CHP representative attendance was raised, and it was confirmed that the General Managers of each of these CHP’s did receive the agenda and papers and were welcome to attend. It was also noted that Dr Cormack previously attended the SE Highland CHP meetings to represent SSU, however due to his retiral, Mr Denholm was currently looking at how SSU could continue to be represented at the CHP meetings. Action: S Denholm
2 / NHS Highland Board Meeting – 6 June
Miss Fraser gave an overview of the discussions at the Board meeting held on the 6 June and advised that 3 new Non-Executive Members from Argyll and Bute had been in attendance.
Members noted that 2 business cases had been presented at the recent meeting, namely:
Interventional Cardiology
Members noted that the Board approved the business case, and agreed to include it in the financial plan.
Replacement Linear Accelerator Business Case
Referring to the above business case, Miss Fraser advised that following discussion at the Board, DHS had been asked to scrutinise the case further and report back to the Board in September. Action: L Lawrence (DHS Agenda)
Members also noted the request for lead colleagues to be identified for both business cases. It was noted that Susan Eddie would confirm these with Neil McLennan who has been identified as the Project Manager for these developments. Action: S Eddie
Miss Fraser also referred to discussions held around the Women’s Health Network and suggested that an update on progress be give at a future SSU Governance Committee meeting. Action: A Ward
3 / Minute of meeting held on 12 April 2006
The minutes of the meeting held on 12 April 2006 were approved as an accurate record subject to the following amendments:
Page 1 Include: Dr DAR Lees under those present
Page 4, Item 7, 2ndPara: Replace “removing” with “transferring”
4 / Matters Arising/Actions
CHI Improvement Programme
It was suggested that an update on the above programme be included in the General Manager’s report for the September meeting. Action: S Eddie/L Lawrence
Mr Hobson referred to the issues around the discharge letter, and confirmed that a meeting had taken place which resulted in a number of action points currently being taken forward. Action: N Hobson
Infection Control/HAI
Members noted that there had been no recent feedback from the Environmental Cleanliness Group. Mr MacRae advised members, that Norman MacLeod had given an update on progress to date at a previous Formal SSU Management Team meeting, but that the national monitoring tool, did not focus on infection rates specifically.
Members noted that the cases of D&V within Ward areas had increased in the last year, with every Ward appearing to have had a period of D&V at some point. Mrs McClurg advised that this could be attributed to the hospital being at full capacity on a regular basis. Members noted that this was the same pattern as in all major hospitals.
A request was made for an update to be included in the General Manager’s report for the September meeting. Action: S Eddie/L Lawrence
Communications
Members noted that there had been an issue around the accessibility of communications staff at Raigmore, however to date SSU have managed to continue to secure a presence on site.
Referring to the SSU Communication Plan, Ms Eddie confirmed that feedback on the action plan needed discussion with the Communications Team. Action: S Eddie
Services for Older Adults in Sutherland
Members noted that the site identified for the redesign of the service had now been purchased.
5 / General Manager’s Report (Key Performance Indicators)
Miss Fraser commented on the circulated paper and advised members that it was felt that the format of the report, was the most effective way of encompassing the updates of all the KPI’s.
Ms Eddie advised that she would welcome feedback on the information detailed in the document and whether this gave a true flavour of the activities etc within SSU.
It was suggested and agreed that it would be useful under the inpatient and outpatient activity sections to provide a graph showing a year on year comparison ie. 1st Qtr – this year/last year etc. Action: S Eddie
In relation to section Availability Status Codes (ASC), it was noted that “Medical Constraints” was defined as patients medically unfit for operation, and to clarify this the code should possibly be renamed “medical condition constraints. Action: S Eddie
In relation to the patient deferred code it was noted that a number of patients had not turned up for list largely due to the holiday period. It was noted that this links into how far ahead the appointment was issued to patients, and it was acknowledged that on some occasions, appointments were issued at relatively short notice although this contravened the aim of the Patients Access Policy, currently out for consultation.
A request was also made for a section on cancer wait times to be included in future reports. Action: S Eddie
In relation to the emerging issues section, the following sections were highlighted:
Recruitment of Night Practitioners
Request for a more significant update to be include in the next report.
Action: S Eddie
Patient Access Policy
Members noted that the draft policy was currently out for consultation, with a deadline for comments to Brian Devlin, Executive Assistant by the end July 2006.
Agenda for Change
Mr Hobson, for the benefit of Mr Smith explained the issue around the impact of sick leave payments.
Complaints/Commendations
Mr Smith voiced concern at the quality of input by MSP’s in a number of complaints which were presented via local MSP’s on the constituents behalf. It was suggested that the issue be raised via the Highland HealthVOICES Network. Action: G Smith/J Thompson
6 / Health Improvement
Tobacco Strategy Action Plan
Member noted that the Working Group had not met for some time, and although progress was being made, there were some areas of concern, eg. Elderly patients smoking outside the hospital, which have not been resolved. It was suggested that the group required to be reconvened to take forward the issues raised. Action: D Seago
In relation to smoking cessation, it was noted that investment had been made to take this forward. Ms Jennifer Larsen, Smoking Cessation Adviser is dedicated to SSU on a part-time basis. It was felt it would be useful to provide a 6 monthly report on the progress made within SSU. Action: S Eddie/J Larsen
Ms Steer informed members of the recent offer of a patient/public campaign in the form of a leaflet explaining the policy of smoking. It was suggested that this could be progressed through the Unit General Manager and the Tobacco Working Group.
Members noted that there had been discussion around bringing forward the smoke free site options. Mr Seago to feedback to Ms Eddie on progress. Action: D Seago/S Eddie
Ms Steer added that Argyll and Bute had introduced a smoke free site policy and this policy would continue to be enforced in the area. The issue around the quality of the signs was raised and it was agreed that Mr MacRae would take this forward. Action: D MacRae
Pandemic Flu
Dr Henderson circulated a paper detailing pandemic influenza planning and advised that although an NHS Highland Contingency Plan was in place, this was essentially a strategic plan and there was a requirement for a plan to be taken forward on a local level and in a co-ordinated way for NHS Highland. It was noted that Mr MacRae and Dr Rob Peel would be taking this forward, with the support of colleagues within SSU and the Public Health Department. A meeting to take this forward to be arranged in the near future. Action: D MacRae
Ms Eddie wished to thank Dr Henderson for his support and hoped that continued support would be available from Public Health when Dr Henderson leaves his post at the end of the month.
Dr Henderson advised members of the visit on Friday 28th July with two members of the Scottish Executive’s Pandemic Flu Co-ordination Team to Raigmore. It was agreed that those involved in the visit, would require to be informed fully and a draft plan in place prior to the visit. Action: D MacRae/S Denholm
Health Improvement – Raigmore
Ms Eddie advised that she had recently discussed the option of a stocktake eg. HAI, Food and Nutrition with Jane Groves, Health Promotion and this would be progressed in the near future.
Mrs McClurg commented that as chair of the Food Fluid and Nutrition Steering Group the minutes of the meetings were circulated to Mr Hobson, Charge Nurses and Ms Eddie routinely. It was agreed to include Jan Henderson, Health Promotion in the circulation of the minutes. Action: L McClurg
7 / Staff Governance – Progress Report on Actions from Workshop
Miss Fraser advised that a report had been received from the Medical Directorate only to date. A request was made for a documented report from each of the Directorates for discussion at the next meeting. A copy of the template developed by the Medical Directorate to be issued to the DGM’s. Action: L Lawrence
8 / Financial Governance
Ms Hogan gave an update on the financial position and reported that there was a £300K overspend to date, with £1.1M of recovery plans still to be achieved. A strict target by the Chief Executive by the end of August has been set, and work is continuing towards achieving these targets, whilst being mindful of the emerging issues in drugs and radiology. Ms Eddie added that a meeting has been scheduled with Elaine Mead, tomorrow to discuss how this target would be achieved. Action: S Eddie/K Hogan
Members noted that a vast amount of work was being undertaken in relation to the Agenda for Change budgets.
Members also noted that Ms Eddie and Mr Denholm had attended the Financial Planning Meeting last Friday, at which the Highland picture and individual savings plans were discussed. Proposals for developing community teams were presented to the Group, however funding would only be granted, if savings could be made. In terms of the fire alarm plan within SSU, CHP’s had been asked to look at the options available to free the pressure on the SSU beds.
Mr Denholm commented that he had visited the RNI recently, and it was clear that at present there was no short term fix. Solutions are being discussed, although these would need to be within the financial constraints.
Members noted that the bid for a Project Manager for A&E/OOH had not been funded.
Members were asked to forward any suggestions for additional savings to Ms Eddie. Action: All
9 / Clinical Governance
SSU Clinical Governance Performance Report
Mr Denholm advised that he had met with Mirian Morrison recently regarding reporting on SSU performance. It was felt that the circulated document seemed a reasonable starting point at this stage. Whilst accepting the template as reasonable, comment was made around the quality of the data, and it was suggested that the figures shown were unrepresentative of the actual figures.
In relation to the clinical effectiveness section it appeared that only a small amount of audit work was undertaken and this was clearly not the case. It was suggested that Mr Denholm and Ms Eddie meet with Dr Smith and Ms Morrison to take this forward. Action: S Eddie/S Denholm
In relation to complaints, Mrs McGauran commented that there were a vast amount of Duty Manager’s complaints which were resolved, but were not recorded within the figures.
In relation to safety incidents, it was noted that the data would appear to include clinical incidents only and would not highlight health and safety incidents.
November Audit Workshop Proposal
Members noted the circulated paper detailing the proposed audit workshop date of 2 November.
Safer Patients Initiative – Application Form
Members noted that a decision had been made to proceed with the application form, which would be completed by Dr Smith, Clinical Governance and Risk Management by the 29 July.
10 / PFPI – Highland HealthVOICES Network
A suggestion was made that Patient’s Council members be sent a copy of the SSU Governance Committee Agenda and would be welcome to attend future SSU Governance Committee meetings. Action: N Hobson
11 / Local Development Plan/Corporate Objectives
Members noted the circulated paper.
Miss Fraser also circulated a copy of the HEAT Measures for information and advised that these had been discussed in detail at the recent Planning Group Meeting.
12 / Delivering for Health – NHS Highland – Clinical Strategy
Members noted the circulated paper and were advised that the document had been endorsed at the recent NHS Board In Committee meeting. Emphasis was made that the document was a “work in progress” with CHP/SSU requiring to produce development plans by the end 2006. Ms Eddie advised that more specific information may be required to assist in the development of local plans.
13 / AOCB
CHP Audit of Governance Arrangements Documentation
Paperwork to be adapted for SSU and completed by end July 2006.
Action: S Eddie
Highland HealthVOICES Network
Members were circulated a copy of the most recent Highland HealthVOICES Network News and details of the current membership.
A request was made for any items of interest within SSU to be forwarded to Ms Thompson, for inclusion in the monthly newsletter.Action: All
14 / Date of Next Meeting
13 September at 3pm – 4th Floor Meeting Room, Raigmore Hospital.`