Highland Nhs Board s2

Assynt House Beechwood Park Inverness IV2 3BW HIGHLAND NHS BOARD Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/

MINUTE of MEETING of the Clinical Governance Committee 14 February 2012 - 9.15am Board Room, Assynt House

Present: Ms Sarah Wedgwood, Chair Dr Ian Bashford, Medical Director Mrs Margaret Davidson, Non-Executive Director Dr Iain Kennedy, Non-Executive Director Mr Michael Roberts, Public Member Mr Alan Simmons, Public Member Dr Margaret Somerville, Director of Public Health Dr Vivian Shelley, Non-Executive Director Dr Lesley Anne Smith, Head of Quality

Also Present: Mr Ian Gibson, Non-Executive Director

In Attendance: Mr Bill Reid, Head of eHealth (item 6.1) Mrs Maryanne Gillies, SPSP Manager/Clinical Governance Manager (item 6.2a) Ms Mary Vance, Local Supervising Authority Midwifery Officer (item 6.4) Dr Grant Franklin, Consultant in Acute Medicine, Raigmore Hospital (item 7.1) Ms Lynn Garrett, Tissue Viability Nurse Specialist, Argyll & Bute CHP (videoconference) (item 7.2) Mrs Mirian Morrison, Clinical Governance Development Manager Miss Irene Robertson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Apologies were noted from Mr Garry Coutts, Mrs Liz McClurg, Ms Heidi May, Ms Elaine Mead and Mr Ray Stewart.

2 DECLARATIONS OF INTEREST

Committee members declared the following interests:

 Dr Iain Kennedy – GP at Riverside Medical Practice, Inverness and BMA Member

 Ian Gibson declared an interest in item 6.1 Clinical Governance within the Quality Strategy and Implications for Integration in his capacity as Chair of the Adult Support and Protection Committee 3 MINUTE OF MEETING HELD ON 8 NOVEMBER 2011

The Minute of meeting held on 8 November 2011 was approved subject to the following amendment:

 Item 8.3 Questions from Lay Members, page 10, first line – “surgical procedure” to read “non-invasive procedure”.

With regard to the rolling action plan the Chair advised that this was in the process of being updated. Dr Vivian Shelley referred to a number of issues which required to be followed up and would liaise with the Chair on any actions to be taken. The Chair confirmed that the rolling action plan would be circulated with the papers for each meeting.

4 MATTERS ARISING

4.1 Surgical Profiles 2011 Action Plan

Mirian Morrison spoke to the updated action plan, copy of which had been circulated, noting progress made to date and highlighting areas of good practice that had been identified across Highland. She confirmed that the document had been submitted to Healthcare Improvement Scotland and their response was awaited. Dr Iain Kennedy noted there was a higher incidence of appendicitis in Highland compared with other areas. The reasons for this were not known, some work might perhaps be done to explore the issue.

The Committee Noted progress to date against the action plan and the ongoing activity to address the issues identified.

5 PERSON CENTRED

5.1 Case Study

The Chair advised that she had discussed the circulated case study, which raised a number of issues about the provision of basic care, with Heidi May, Board Nurse Director. Following their discussion it had been agreed that Ms May would prepare a report for the next meeting on older people’s services, which would touch on arrangements for monitoring basic levels of care. The self assessment from the Healthcare Improvement Scotland review of older people’s services would also be available for consideration at the meeting, the Care Quality Commission’s report on health care and adult social care in England would also play into the discussion. The Committee agreed that it would wish to see the responses made to the complaints highlighted in the case studies brought to its attention, in order to be assured that the issues raised are fully and timeously addressed. The importance of communication was again emphasised, to ensure patients and their families receive all the necessary information and have a clear understanding of what will happen/what they can expect during episodes of care.

The Committee:

 Noted the issues identified in the case study.  Agreed that Heidi May would prepare a report on older people’s services for discussion at the next meeting.

2 5.2 Feedback on experiences of Highland residents treated out of area

Mirian Morrison reported on two pieces of work being undertaken.

Services contracted out to independent providers Information was gathered on governance arrangements to get assurance that any incidents or complaints were investigated and followed up. Some concern emerged during this exercise due to insufficient information being provided. Mrs Morrison has fed back these concerns to the Board’s Service Planning Team who are monitoring the position.

Service Level Agreement with NHS Greater Glasgow & Clyde Mrs Morrison advised there is no central contact point within NHS Greater Glasgow & Clyde for complaints, the process having been devolved to the various directorates, and so there are challenges in collecting data.

There is a general issue around the ability to get information from other boards and independent providers relating to complaints and incidents and their outcomes, and some work needs to be done to improve the position. Mrs Morrison reported on the facility within DATIX to report on incidents involving Highland residents who are being treated outwith the area. She undertook to prepare a report for the August meeting of the Committee detailing the ongoing activity to ensure such complaints and incidents are thoroughly investigated and improvements made where necessary, and to provide assurance that external providers have robust governance systems in place.

The Committee:

 Noted the issues identified and the work ongoing to improve data collection and monitoring arrangements in relation to treatment provided to Highland residents out of area.  Agreed to have an update report at the August meeting.

5.3 Questions from Lay Members of the Committee

The Chair referred to the need to have arrangements in place to facilitate lay members’ participation in meetings and ensure they have the necessary training and support. Discussion followed on how the Clinical Governance Committee agenda is constructed and how our lay members can feed in to the process. The standing item on Emerging Issues affords lay members an opportunity to raise issues. It was accepted that issues introduced at a meeting may require to be deferred to a future meeting so that relevant information can be obtained to address them, or referred to another forum as appropriate.

Two issues had been raised by our lay members, (a) living wills and (b) a perception that more hospital deaths occur at weekends than during the week. Dr Iain Kennedy suggested a useful piece of work might be done on the latter. The data would require careful analysis as there are various different factors leading to patient death which would need to be taken into account. The Chair proposed to follow up both issues with relevant officers and report back to a future meeting.

The Committee:

 Agreed the process for lay members to introduce issues on to the agenda.  Noted that the Chair would pursue the two issues raised and report back to a future meeting.

3 5.4 Emerging Issues a. Scottish Public Service Ombudsman Reports

There was circulated report by Mirian Morrison detailing the complaints investigated by NHS Highland during 2011 which had subsequently been referred to the Scottish Public Service Ombudsman (SPSO). Acknowledging that the number of complaints referred to the SPSO is low, the Committee agreed the need to focus on those which had been upheld, or partially upheld, in order to identify the areas where improvements are required. Mrs Morrison referred to the revised arrangements put in place last year along with the training provided to staff investigating complaints which had led to improvements. Work was ongoing to ensure continuing improvement with the complaints process. In this regard Mrs Morrison advised that an algorithm had been developed and incorporated in the DATIX complaints module, to assist the Operational Units in managing and monitoring complex cases.

On the point raised about ensuring the Committee is timeously informed of complaints that have been referred to the SPSO, Mrs Morrison confirmed that notifications are now issued to the Board Non-Executive Directors on a monthly basis, the Committee is also informed when a case is laid before Parliament.

The Committee Noted the report and the work ongoing to further improve the complaints process

b. Outbreak of Clostridium difficile – Raigmore Hospital

The Chair advised that a report on the learning outcomes from this incident will be submitted to the Committee once the investigations are completed.

Bill Reid joined the meeting

6 STRUCTURES AND PROCESSES

6.1 Clinical Governance Committee – The Way Forward a. Clinical Governance within the Quality Strategy and Implications for Integration

The Chair spoke to her discussion paper which referred to the impending changes in the organisational governance structure of NHS Highland and the implications for clinical governance in the future. There is a need to ensure that audit systems are in place which satisfy the requirements of the individual professions within the integrated teams providing adult and children’s services and assure governance. It was proposed to invite the Head of Adult Social Care to the next meeting to discuss these issues. NHS Highland and The Highland Council will also require to continue to meet their respective statutory obligations within the new structure.

Bill Reid reported on the detailed work underway with Highland Council colleagues around IT systems and support and information management. There will be a straightforward migration of hardware, however as systems migrate there will be a need to ensure that staff can access the records they require to do their job, and that patient and client services and care are not affected by the changes. Discussions are taking place to address data confidentiality issues. The Committee requested that a report be prepared for the May meeting detailing progress with the various work streams, particularly in relation to information governance, and the work that still requires to be done. The Committee would 4 also wish to be assured that each agency will be able to supply the information required for monitoring of routine targets.

Mr Reid advised that there remained a number of issues to be resolved, regular and frequent meetings between NHS Highland and the Highland Council are taking place to consider solutions.

The Committee:

 Agreed that further discussion would be held at the August meeting regarding the governance implications of the new structures.  Agreed to invite the Head of Adult Social Care to the August meeting to discuss the implications for integrated services and the regulatory environment for Social Care.  Noted the joint work underway around IT systems and support and information management.  Requested that Mr Reid provide a detailed progress report on the various work streams to the May meeting.  Agreed that a work programme would be circulated including a number of topics identified during the discussion. b. Highland Quality Approach to Management

Dr Lesley Anne Smith spoke to her circulated paper which gave details of the work ongoing within NHS Highland to develop a suite of Quality Dashboards. She asked the Committee to consider and agree the measures to be included in the first instance in the Clinical Governance/Quality Committee Dashboard which will be reported to the Committee at each meeting. The Committee noted the model developed by NHS Tayside which describes data measurement and reporting at three levels of Improvement, Performance and Scrutiny. Dr Smith reported on the development of a single NHS Highland patient data repository. Work is ongoing to integrate data from North Highland and Argyll & Bute which has a different IT system. It was noted that the data is hospital focused, and concern was expressed about the need to capture community activity as well so that appropriate measures can be set and monitored. The inclusion of social care information in this single repository is a long term aspiration.

The Committee:

 Noted that a Quality Governance Dashboard would be submitted to the August meeting for its consideration.  Requested that Mr Reid prepare an update on the eHealth Strategy, and on eHealth and Social Care systems for the May meeting.

Bill Reid left the meeting

Maryanne Gillies joined the meeting

6.2 Clinical Governance and Risk Management Performance Report a. Scottish Patient Safety Programme

The Chair welcomed Maryanne Gillies, SPSO Manager/Clinical Governance Manager. Mrs Gillies spoke to her circulated report which gave details of the work being undertaken as part

5 of the Scottish Patient Safety Programme (SPSP). She highlighted the two high level objectives of the Programme:-

 Reduce mortality by 15% by the end of 2012  Reduce adverse events by 30% by the end of 2012

NHS Highland is required to assess progress against the National Institute of Healthcare Improvement assessment scale. Mrs Gillies advised that the Board is now on trajectory and is the first board in Scotland to attain a score of 3.5. The next goal is to move up to level 4. The key issue is the spread of the clinical bundles. Spread plans have been prepared for all clinical areas in the four hospitals participating in the Programme (Raigmore, Caithness General, Belford and Lorn & Isles). Progress against spread is monitored in each hospital site. Trends can be identified and learning shared from areas where improvements in terms of both process and outcomes have been achieved.

Ian Gibson left the meeting

In response to a query Dr Margaret Somerville explained how the Hospital Standardised Mortality Ratio (HSMR) is calculated. It was noted that the figure was falling nationally, this is multifaceted and not simply due to the implementation of the SPSP. Work is ongoing to determine whether the HSMR is an appropriate tool for small hospitals, there is also an issue around coding to be addressed.

Thanking Mrs Gillies for her report the Chair proposed to have a presentation on the Programme at a future meeting.

The Committee:

 Noted progress with the implementation of the Scottish Patient Safety Programme and the ongoing work to achieve further spread.  Agreed to have a presentation on the Programme at a future meeting. b. Complaints

Mirian Morrison spoke to her circulated report, noting a deteriorating position from August last year although performance against the 20 day response target has improved since December. Implementation of the DATIX complaints module has commenced in the Operational Units, this will enable the Units to monitor the progress of complaints on line and allow them to access reports for performance monitoring. Additional training has been provided through the Scottish Public Service Ombudsman’s office who have run two courses for managers who act as investigating officers, a further course is planned for later in the month for Argyll & Bute CHP managers. It is also intended to develop in-house training. It was noted that the national NHS complaints procedure is being reviewed to take account of the Patients Bill of Rights and is currently out for consultation. There will be some requirements on Boards in respect of their complaints processes and arrangements. It was agreed to circulate a copy of the draft national procedure to the Committee members for their information and consideration. Mrs Morrison advised that the new Patient Advice and Support Service (replacing the Independent Advisory and Support Service) would come into effect on 1 April 2012. Another initiative, ‘Patient Opinion’ which comes under the Better Together national programme and aims to capture patient feedback, is being piloted in Highland.

6 The Committee:

 Noted the position with regard to meeting the 20 day response target for complaints and the ongoing work to improve performance.  Agreed to request that Mrs Morrison prepare a further breakdown on complaints, viz location, type, subject, response time, and some detail regarding the complexity of complaints.  Agreed to circulate the draft revised national NHS Complaints Procedure to the members for information and comment.  Agreed to have a progress report on the implementation of the Patient Advice and Support Service at the August 2012 meeting. c. Incident Reporting

There was circulated incident report, presented in the new dashboard format, which provided incident data relating to Quarter 3. Mirian Morrison explained that the dashboard module within DATIX allows incident data to be analysed and displayed in graph format and provides the organisation with an electronic annual and quarterly report. Draft dashboards have been developed, the Highland wide incident dashboard and the Raigmore and Argyll & Bute CHP dashboards are now fully operational. Dashboards for the new North & West Highland and South & Mid Highland operational units will be developed in preparation for the new financial year. In addition a dashboard for each of the top ten categories of incidents, including falls and tissue viability, is being produced, these dashboards will be available at ward level. Further discussions will take place with the Health and Safety Team to develop specific dashboards to support their role.

Mrs Morrison would welcome the Committee’s views on the revised reporting format and whether it would provide the necessary assurances. Dr Iain Kennedy described the process for adverse event reporting in the primary care setting, noting that this does not link in with the DATIX system. Consideration would need to be given to addressing this gap.

An issue was raised about consent in terms of improvement to patient experience and care. Mrs Morrison advised that a working group would shortly be meeting to review the Policy for Consent to Treatment, Surgery and Invasive Procedures and associated forms.

The Committee:

 Remitted to its members to further consider the revised incident report format and let the Chair and Mrs Morrison have any comments as to its usefulness and whether they are satisfied it will provide the necessary assurance.  Agreed to consider the revised Policy for Consent to Treatment, Surgery and Invasive Procedures at a future meeting.

Margaret Davidson left the meeting

6.3 Clinical Governance Forum

Mirian Morrison spoke to her circulated report which provided a summary of the topics discussed by the Clinical Governance Forum during 2011 and the outcomes of these discussions.

7 The Committee Noted the report.

Mary Vance joined the meeting

6.4 Local Supervising Authority Midwifery Officer’s Annual Report to the Nursing and Midwifery Council 2010 – 2011

The Chair welcomed Mary Vance, Local Supervising Authority Midwifery Officer for North of Scotland Region. Mrs Vance spoke to the circulated document, noting that Local Supervising Authorities are required to submit an annual report to the Nursing & Midwifery Council (NMC) which provides the detail of how they meet the required standards for the statutory supervision of midwives. Highland had met 53 of the 54 standards. The standard relating to supervisory investigations and reporting incidents had been partially met, some improvements are required to ensure a robust system is in place. Mrs Vance advised that an action plan had been developed in response to the recommendations made by the NMC, a copy of which would be circulated to the Committee. As the annual report covered the North of Scotland Region Mrs Vance had prepared a briefing paper detailing the position in Highland which she would also circulate to the Committee for its information. An issue was raised in relation to the numbers of midwives in training to be supervisers. While some progress had been made in this area Mrs Vance highlighted the need to implement a robust recruitment and retention strategy across the North of Scotland to ensure the sustainability of the supervisory framework. In response to a query about how the standards relate to quality of care and outcomes for people using the services, Mrs Vance outlined the role of the Maternity Services Strategy and Coordination Group in taking forward this work.

The Committee commended Mrs Vance for her very thorough and useful report. Noting that the standards are currently being reviewed, the Committee agreed to have an update on the position in six months’ time at its August meeting. It was proposed to invite the Chair of the Maternity Services Strategy and Coordination Group to the meeting to report on the issues. It was also agreed to request that this Group produce an annual report for submission to the Committee.

The Committee:

 Noted the LSAMO Annual Report 2010 -11 to the Nursing & Midwifery Council .  Agreed to have an update on the position at the November meeting and to invite the Chair of the Maternity Services Strategy and Coordination Group to attend to report on the issues.  Agreed to request that the Maternity Services Strategy and Coordination Group submit an annual report to the Clinical Governance Committee.

Mary Vance left the meeting

Grant Franklin joined the meeting

7 SAFE

7.1 Resuscitation Committee

The Chair welcomed Dr Grant Franklin, Consultant in Acute Medicine, Raigmore Hospital. Dr Franklin spoke to the circulated annual report of the Resuscitation Committee. He explained that the committee had been in abeyance for a couple of years but was re-

8 established in February 2011 and has subsequently met on four occasions. He summarised the main topics discussed at the meetings. These included, among others, the Resuscitation Policy, the 2222 Bleep Policy, Resuscitation Training Figures and Resuscitation Audit Figures. Dr Franklin highlighted ongoing challenges in the recording of data on 2222 calls and other resuscitations. The resuscitation record had been modified to capture both audit data and clinical information on the same form, however data collection remains problematic. There are education and cultural issues to address, to ensure all junior doctors are aware of the importance of completing a form for each resuscitation incident irrespective of its severity and embed this as good practice. Dr Franklin confirmed that this element was part of the induction programme. He also highlighted the need for more administrative support for data collection. The committee will continue to look at ways of improving data collection and analysis in order that clinical outcomes can be identified and used to inform actions. Dr Franklin referred to the ongoing challenge of ensuring inclusive representation on the committee from across Highland and not just from within Raigmore.

Thanking Dr Franklin for his comprehensive report, the Chair suggested that the position with regard to representation on the Resuscitation Committee could be highlighted at the various Clinical Governance and Risk Management Groups to raise awareness of this issue and the other challenges he had identified. With regard to data collection, it was noted that crash call rates are collected as part of the dashboard and that there is an opportunity to link in with the medical emergency team to rationalise the process.

The Committee Noted the annual report of the Resuscitation Committee for 2011 – 2012, the issues identified and the ongoing work to address them.

Dr Franklin left the meeting

Lynn Garrett joined the meeting by videoconference

7.2 Tissue Viability – Pressure Ulcer Prevention

The Chair welcomed Lynn Garrett, Tissue Viability Nurse Specialist, Argyll & Bute CHP who spoke to the circulated report which detailed the current status of pressure ulcer incidence across NHS Highland and the range of initiatives and actions in place to improve care. The report noted the impact of pressure ulcers on patient health and also the financial cost. Ms Garrett referred to the Zero Tolerance approach adopted by NHS Highland, and the ongoing implementation of the Clinical Quality Indicator for pressure ulcer prevention across all hospital sites. Some targeted improvement work has been done in wards at Raigmore, learning points from this exercise will be shared across the area. It was suggested that there may be learning to be gained from the Stroke Unit where the incidence of pressure ulcers is low; a higher rate might have been expected given the underlying conditions and reduced mobility of the patients in the Unit. The need to develop stronger links with the community was highlighted to support the provision of quality care and the prevention of pressure ulcers.

Noting the report, the Committee agreed to request a further report for its August meeting and to have six monthly updates thereafter.

The Committee:

 Noted the current position and the ongoing work to reduce the incidence of pressure ulcers.  Agreed that a further report be submitted to the August meeting and that six monthly updates be provided thereafter.

9 7.3 Healthcare Improvement Scotland (HIS)

Mirian Morrison gave a brief update, noting that there was no further information available at present regarding the consultation on the HIS Quality Standards. With regard to recent/ forthcoming HIS reviews, Mrs Morrison indicated that the panel looking at Neurology Services would convene on 29 February 2012, a report on the outcome would be given in due course. Older People’s Services would be discussed at the May meeting.

The Committee:

 Noted the position in relation to the HIS Quality Standards consultation.  Agreed that Older People’s Services would be included on the agenda of the May meeting and that the outcome of the Neurology Services review would be reported to a future meeting.

7.4 Falls Prevention

The Chair explained that as Heidi May, Board Nurse Director was unable to be present this item would be deferred to the next meeting when Ms May would present a report about care of the elderly and dementia which would encompass the three areas of harm on which the Committee wished to focus, viz falls, medication and pressure ulcers. It was proposed that the Committee should receive a six monthly report on performance in these areas, in order to monitor the position and get assurance that appropriate action is being taken to make improvements as necessary.

The Committee:

 Noted that Heidi May would submit a report to the next meeting on care of the elderly and dementia services and that falls prevention would be part of the discussion.

8 EFFECTIVE

8.1 Record Keeping Audits

Mirian Morrison spoke to the circulated report by Rachel Hill, Clinical Governance Manager detailing progress on a range of audit activity within the professions to gather information about, and make improvements to, record keeping practice. Specific audit tools were developed for use in General Nursing, Public Health Nursing, Midwifery and the Allied Health Professions, and audits in these areas are undertaken on a regular basis. A Dental record keeping audit tool has been developed, consideration is currently being given to its implementation. With regard to Medical record keeping audit, an audit tool designed around the Academy of Royal Medical Colleges’ ‘Clinician’s Guide to Record Standards’ was considered by the Area Medical Committee in 2010. The Area Medical Committee had felt that the tool was too complex and lengthy, it did not provide a reasonable sample size, and the rapid turnover of junior staff would make it difficult to implement this particular audit system. For these reasons the Area Medical Committee did not recommend the wider use of this audit tool, but that it should be available to practitioners should they wish to use it. It was noted that medical records are being audited at the Caithness General Hospital. The Committee agreed to get feedback on the outcome of these audits, it also agreed to request the Area Medical Committee to further review the tool.

10 The Committee:

 Noted the paper.  Agreed to obtain feedback on the medical record keeping audits being undertaken at Caithness General Hospital  Agreed to refer the medical record keeping audit tool to the Area Medical Committee for its further consideration.

9 FOR INFORMATION

9.1 Reports from Operational Units

The following minutes were circulated:-

 Argyll & Bute CHP Clinical Governance and Risk Management Group minute of meeting held on 22 September 2011

 Mid Highland CHP Health & Safety and Clinical Governance Group draft minute of meeting held on 7 December 2011

 North Highland CHP Clinical Governance and Risk Management Group minute of meeting held on 4 November and draft minute of meeting held on 20 December 2011

 Raigmore Hospital Quality and Patient Safety Management Team minutes of meetings held on 19 October and 16 November 2011

 South East Highland CHP Clinical Governance and Risk Management Group minute of meeting held on 3 November 2011

Discussion followed on the level of assurance that minutes could provide and what other effective means the Committee might utilise to assure itself of governance.

The Committee Noted the Minutes.

10 CLINICAL GOVERNANCE COMMITTEE ANNUAL REPORT 2011 – 2012

The Chair reminded the Committee that an annual report detailing its activities during 2011 – 2012 required to be submitted to the May Audit Committee. She advised that she would draft the report and circulate it to the members for their comments in advance of the next meeting.

11 DATE OF NEXT MEETING

The next meeting will be held on Tuesday 8 May 2012 at 9.15am in the Board Room, Assynt House, Inverness.

The meeting concluded at 1.05 pm