Item 8.10 for 1 Jun 2010 CGC Minute

APPROVED Minute of Meeting of the NHS Grampian Clinical Governance Committee held on Friday 19th February 2010 at 9.30am in the Conference Room, Summerfield House, Eday Road, Aberdeen

Present: Mr L Bell, Non-Executive Board Member Board Meeting Professor N Haites, Non-Executive Board Member (Chairman) Open Session Mr T Mackie, Non-Executive Board Member 01 06 10 Professor V Maehle, Non-Executive Board Member Item 8.10 Mr M Scott, Non-Executive Board Member

In Attendance: Mr B Archibald, Service Planning Lead for Oral Health and Dentistry (Agenda Item 3.2) Dr M Bearn, Clinical Governance Lead, Moray Dr J Callender, Clinical Governance Lead-Mental Health Services Dr D Cameron, Chairman, NHS Grampian Mr R Carey, Chief Executive Ms L Dawson, Strategic Change Manager (observing) Dr R Dijkhuizen, Medical Director Ms J Gibb, Head of Nursing Mrs P Harrison, Interim Infection Control Manager Ms S Inkson, Administrator (shadowing Mrs Shepherd) Mr A Jackson, Legal Advisor Mrs B Lurie, Team Leader & Clinical Effectiveness Facilitator (Agenda Item 5.3) Mrs L Oldroyd, Nurse Consultant Patient Safety & Experience(Agenda Items 4.2, 11.1 & 11.2) Mr T O’Kelly, Group Clinical Director (attended on behalf of Dr E Robertson) Mr G Poon, Clinical Governance Lead – Aberdeen City CHP Ms H Robbins, Head of Clinical Governance & Risk Management Mrs J Ross, Medication Safety Officer (Agenda Item 6.2) Mrs J Seaton, Technical Services Manager (Agenda Item 6.1) Mrs E Smith, Nurse Director Ms F Soutar, Strategic Change Manager (observing) Mrs N Urquhart, Public Representative Dr L Wilkie, Director of Public Health 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. Item Action 1 APOLOGIES Apologies were received from: Mr C Muir, Dr R Gatenby, Dr E Robertson and Dr P Strachan.

2 MINUTE OF MEETING HELD ON 4th December 2009 The Minute of the meeting held on 4th December 2010 was accepted as an accurate record subject to the below amendment:

The title Unit Clinical Director to be changed to Medical Lead – Acute Sector on pages 1 and 9.

3 MATTERS ARISING 3.1 Update from Surgical Profile Panel Ms Robbins updated the Committee on the progress on the Surgical Profile 1 work and the recent feedback from the National Panel.

The second iteration of the Surgical Profile was made available to NHS Boards in December 2008. Each NHS Board was asked to provide a written response to its Profile, by April 2009, describing how the data are being reviewed and acted upon locally (including a detailed action plan). In the Spring of 2009, the Surgical Profile Review Panel met to consider the responses received, and in June 2009 a letter had been sent to each NHS Board providing feedback from the Panel (in some cases seeking additional information). All NHS Boards that had ongoing actions in response to the Profile were asked to provide an update on these actions by December 2009. This update was submitted according to the deadline in December 2009. The Panel met in January 2010 to consider the submissions.

The third round of data will be released for consideration and action late 2010.

NHS Grampian had engaged fully and enthusiastically with the Surgical Profile data and improvement work. The data had been assessed by the National Panel in January 2010 and NHS Grampian was commended on our systematic approach.

There was a requirement to maintain momentum with this approach, throughout the remainder of the year and when the third round of data is released governance structures need to continue to seek assurance on this work.

The Committee considered this to be an excellent piece of work by Grampian in taking forward a national programme and acknowledged the potential for this approach to identify areas of performance and practice that required improvement; examples of how this was happening given by the Lead Clinician Mr O’Kelly.

The Committee noted the report and NHS Grampian’s outcome of the National Review Panel.

The Committee agreed that Surgical Profile will be reported to the Board.

3.2 NHS Grampian Dental Premises and Dental Practice Risk Assessment As agreed at the previous Clinical Governance Committee meeting a further report from Dentistry was requested on Decontamination, Risk Register and Dental Premises Strategy. The Chairman welcomed Mr B Archibald, Service Planning Lead for Oral Health and Dentistry to the Committee.

Mr Archibald presented to the Committee the report which highlights the physical planning, clinical governance and risks. Mr Archibald informed the Committee that initial 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 Committees attention a number or concerns; the main one being infection control which was an issue around decontamination. The service was experiencing problems coping with increased demand and work was being undertaken to address this area of concern.

2 Mr Archibald referred to his report and highlighted the main points as below:  The risk assessment highlighted that there are community dental service premises that had not been inspected.

 Plans are in place to re-locate dental practices where their premises are not complying with new regulations.

 Support is being provided to 20 dental practitioners to achieve Local Decontamination Units (LDU) compliance.

 In order for the North of Scotland and Grampian to capitalise on the national dental workforce plan the Dental Plan estimated an increase of over 100 dentists over a 4 year period. 22 independent dental practitioners had been recruited.

Mr Archibald informed the Committee that NHS Grampian was developing a dental premises strategy by March 2010 to incorporate risk areas. They would ensure that each CHP had full involvement and agreement with the strategy.

Mr Carey welcomed the report and issues identified. Mr Carey also welcomed the development of a NHS Grampian dental premises strategy. Mr Carey brought to the Committee’s attention around the funding situation; a number of services had withdrawn from the service and had not been replaced. Mr Archibald clarified that the withdrawn services were primarily within schools.

A question was raised around the challenges in recruiting dental nurses. Mr Archibald responded that he had started developing a number of initiatives to improve opportunities in recruiting dental nurses.

The Committee noted the paper and agreed the recommendations as detailed. The Committee asked to receive a progress update in 6 months.

4 PATIENT SAFETY 4.1 Scottish Patient Safety Programme Update Mrs Smith presented the paper prepared by Mrs J Ingram, SPSP Programme Manager and updated the Committee as highlighted below:

 NHS Grampian was at the required level of the assessment scale, ie level 3.  The progress being achieved within the work streams was described: critical care, general wards, medicines management, paediatrics and perioperative.  Patient Safety Walk rounds by the Executive team were now well established and areas for improvement were being taken forward.  The Global Trigger Tool was being used to identify our level of harm events and this information was then used for improvement.

Areas out with the programme being developed include:  A corporate quality and safety dashboard.  An education framework for under/post graduate and NHS Grampian staff

3 which focuses on an integrated learning approach to quality and safety.  Working with other areas of improvement so that tools were integrated and agreed, with the development of Technique cards for use across NHS Grampian.  Aberdeenshire and Mental Health were implementing patient safety action plans.  Working with the Cardiac MCN on National Coronary Heart disease patient safety bundles.

Mrs Smith informed the Committee on the areas of achievement which included a very successful seminar day at Dr Gray’s Hospital which included the National Scottish Patient Safety Programme team and leaders from the Institute of Healthcare Improvement (IHI). Approximately 80 staff attended and several areas of work were praised by the national team.

Mrs Smith highlighted from the report identified risks around this work and the Committee acknowledged these risks and the controls that were being put in place. The risks relate to the difficulty in continuing to maintain progress and sustain the improvements achieved to date. The controls related to working with others such as Practice Educators and the Infection Team to spread improvement tools and enhance staff education.

The Committee noted the progress made to date.

The Committee agreed that Patient Safety will be reported to the Board.

4.2 Better Together Update Mrs Oldroyd presented to the Committee an update on the Better Together Programme. Better Together was Scotland’s national Patient Experience Programme.

The purpose of this is survey is to collect patient experience information and ensure that survey results were used to direct and inform improvement work.

The Survey comprises of three separate groups: 1. GP Survey: The administration of the GP survey is being done nationally. It was expected that Boards will receive results in late Summer 2010.

2. In-patient Survey: Surveys were distributed to a sample of over 8,000 patients in NHS Grampian who had had an overnight stay in an Acute Hospital over the past 12 months. Results were expected in Autumn 2010.

3. Long term conditions Survey: aimed at patients with a long term condition will be carried out later in 2010. First planning meeting in April 2010.

A project group led by Mrs Laura Gray had convened to oversee the administration of the in-patient survey.

Mrs Oldroyd referred to the recommendations in the paper and asked the Committee for their comments around; who would be responding to stories posted on the website, ratifying and signing off on behalf of NHS Grampian; 4 Should a Patient Experience Reference Group be convened around this work.

Mr Carey referred to the recommendations and suggested using the existing procedures that were in place around Corporate Communications and the Feedback Service.

Mr Scott commented that he felt that this was a helpful tool to see patient stories.

5 NHS GRAMPIAN - CLINICAL GOVERNANCE COMMITTEE - AREAS OF ASSURANCE DEVELOPMENT 5.1 Assurance Plan & Revised Areas of Assurance Development Ms Robbins referred to the paper and highlighted that the Committee has had an Assurance Plan for several years. The Assurance Plan had been revised following the strategic objectives. Previous plan was rather long and detailed.

The Assurance Plan had been re-designed to present to the Committee a clearer more structured level of detail for the work of the Committee and to link the work with various influencing forces and priorities such as strategic objectives, risks and national issues.

The Committee noted the recommendation in the paper to approve the revised Clinical Governance Committee Assurance Plan.

5.2 Clinical Risks Ms Robbins referred to the paper prepared by Ms Robbins and Mrs Seaton, Technical Services Manager and highlighted that this was the first time that a report on strategic clinical risks had been presented to the Clinical Governance Committee.

The clinical risks within the strategic risk control plan were presented to the Committee as a pilot and to ask the Committee to consider that this features as a regular item for reporting to the Committee. This will then be rolled out to other Committees. The Committee acts as an assurance source for some of the risks identified in the plan.

Ms Robbins highlighted the aim was to provide the Clinical Governance Committee with sufficient information on the clinical risks to provide assurance to the Board directly and via Performance Governance Committee.

Ms Robbins went through the report and highlighted key points as detailed below:  Table 1 on page 2 illustrates the three risks which were allocated to the Clinical Governance Committee; Patient Safety; Community and Independent contractors and Alignment of Strategy with intelligence, learning and resources.

Ms Robbins mentioned that a workshop took place for the members of the Operational Management Team on the 9th February 2010 to refresh the

5 corporate operational risk control plan. It concluded that the operational risks sit with the Sectors and Service areas and will be reported or escalated to the Operational Management Team.

Mr Carey commented that we need to keep operational risks for sector service areas in order to provide assurance through that process.

The Committee noted the report and agreed the recommendations.

5.3 Grampian Wide Audit of Nursing Record Keeping The Chairman welcomed Mrs B Lurie, Team Leader/Clinical Effectiveness Facilitator who was invited to the Committee to present on the Grampian Wide Audit of Nursing Record Keeping.

Mrs Lurie provided some background information on the audit and mentioned that the aim of this project was to develop a Grampian wide system to review the quality of nursing record keeping within NHS Grampian. Electronic audit packs were developed and an excel spreadsheet automatically generated a score for each record audited. The maximum score that could be achieved was 100%. The overall score for NHS Grampian was 79%. The results detailed good practice and also areas for improvement. To proceed to the next step a discussion was required with the Senior Nurse Group on how the information gained from the audit was used as there were system wide implications from the results for eg record design, training and education.

Mrs Lurie highlighted key points from the report as detailed below:  Each nursing team had ownership of their results and had developed an action plan to implement any required changes that had been identified in the audit.

 A global email was sent to staff to advise that the overall audit results were available and to draw attention to staff the requirements of their professional guidelines i.e. Nursing and Midwifery Council, Record Keeping: Guidance for nurses and midwives (July 2009).

Mrs Lurie highlighted to the Committee that a key risk to the organisation was around the poor quality of nursing record keeping in NHS Grampian.

Mrs Lurie concluded that the Committee can be assured that NHS Grampian now had information about nurse record keeping and will continue to work with Senior Management on improving the quality.

The Committee commended the work undertaken by the Clinical Effectiveness Team around this audit. There was discussion in the Committee around the terminology when reporting results as the expectation from the public would be that record keeping should be 100%.

Dr Dijkhuizen informed the Committee that an audit was underway on Medical Record Keeping. Dr Dijkhuizen commented that it would be worthwhile having an NHS Grampian organisational wide combined Nursing and Medical Record Keeping Framework.

Mrs Lurie informed the Committee that an abstract for a poster presentation around this work had been successfully accepted at the National Clinical 6 Governance Conference in Glasgow on the 2nd March 2010.

Committee members asked if NHS Grampian should have a Record Keeping Policy. Mrs Lurie mentioned that this was something we need to look at, taking into the record keeping standard.

Dr Callender asked if it would be possible to receive a detailed breakdown of the Summary of Results for the sectors. Mrs Lurie agreed to provide this BL information to the individual sector/service areas.

The Committee noted the report.

6 QUALITY & SAFETY 6.1 Datix Occurrence Reporting 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 this report focuses on the data from the incident module and to provide an overview of the patient related incidents recorded on the system and the comparison between 2008 and 2009 incident reports.

Mrs Seaton talked to the report and highlighted the key points as detailed below:  73% of the incidents reported on the Datix system relate to patients.

 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).

 31% of incidents reported in 2009 23% were patient related.

 There had been a positive increase in reporting of medication incidents.

 The “other” coding was being reviewed to analyse absconding patients which were often being miscoded. This will be completed prior to the next report to the Committee.

 There was more detail around significant incidents with a severity grading of high or catastrophic; incidents that result in a death or multiple low grade incidents. Managers were expected to review the severity grading which was originally entered by the reporter.

 Services with high and catastrophic incidents that had not been reviewed now had a trigger put in to email to senior staff to review these incidents quickly.

7  Senior Managers in the Acute Sector now receive email notifications when incidents were reported as high/catastrophic or deaths. A formal review was planned for March 2010 in order to consider rolling this out.

Dr Dijkhuizen commented that it was very important how the process is developing to re-assure and increase in quality. Dr Dijkhuizen referred to Table 3 in the paper and highlighted that some of the figures were incorrect.

The Chairman thanked the Committee for their comments and suggestions on future reporting requirements to the Committee.

The Committee noted the report and agreed the recommendations.

6.2 Medication Safety The Committee was informed of the report submitted by Mrs Ross, Medication Safety Officer. The report gave details of the work being done to improve medication safety within NHS Grampian. The redesign of the Medication Safety Committee was described, along with the increasing use of Datix incident data and associated work to try and reduce adverse events. Medication was one of the work streams for the Scottish Patient Safety Programme (SPSP) and a number of areas were being implemented as part of this programme.

The Committee considered the progress presented but stated that further information was required before they could be satisfied that assurance had been given. The Committee asked that this item should be presented again at a future Committee meeting to provide more detailed assurance that this JR work was having a positive impact on improving patient safety.

The Committee agreed that Medication Safety will be reported to the Board.

7 CHILD PROTECTION There was nothing further reported as Mr Pilkington was not present at the meeting.

8 HEALTHCARE ASSOCIATED INFECTION UPDATE Mrs Harrison presented a paper prepared by herself and Dr R Dijkhuizen, Medical Director which detailed the current HAI priorities, Healthcare Environment Inspectorate (HEI) Improvement Action Plan and the RAG Report (red, amber, and green). Mrs Harrison informed the Committee that this paper had also been reported to NHS Grampian Board.

Clostridium difficile: Good progress was being met in the reduction of infection cases recorded in NHS Grampian’s hospitals. Progress was being made with General Practice and Community Hospitals. Staphylococcus Aureus Bacteraemia: Although a lot of progress was being made in the incidence of MRSA bacteraemia we were not on track to meet the HEAT target for March 2010. If NHS Grampian fails its HEAT target it will be by a relatively small margin.

Mrs Harrison informed the Committee that NHS Grampian will not be an outlier and that there were a number of other Board areas that do not meet this HEAT target. 8 Cleaning Specification Compliance: The recent Healthcare Environment Inspectorate (HEI) visit highlighted that the National Monitoring Framework for cleaning had a different level of rigour than the HEI audit framework. An Action had been taken to introduce more robust cleaning inspections.

The fifth bi-monthly national Hand Hygiene audits showed that 15 audits in NHS Grampian had an average compliance rate of 94%.

Healthcare Environment Inspectorate (HEI) – NHS Grampian Improvement Action Plan: Mrs Harrison 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 inspection. The outstanding actions had been transferred to the Healthcare Associated Infection Work plan. There were only 2 high risks around cleaning left on the Healthcare Associated Infection Risk Control Plan.

Mr Bell informed the Committee that he attended an informal unannounced HEI visit at Dr Gray’s Hospital along with Mr Muir. Mr Bell felt that this was a very worthwhile experience and recommended it to other non-executive board members.

Dr Dijkhuizen highlighted to the Committee that infection rates for Clostridium difficile and Staphylococcus Aureus Bacteraemia had reduced dramatically. The main goal for NHS Grampian was to achieve the best HAI rates in Scotland by the end of next year.

Dr Dijkjhuizen informed the Committee that there was another unannounced HEI inspection visit to Acute Sector on Thursday (18th February 2010). The verbal feedback received seemed to be very positive with a tremendous amount of progress being recognised.

The Committee had a discussion around staff morale and anxiety in the public after the HEI Inspection in October and it was felt there should be an exercise to install staff and public confidence.

The Chairman commented that a meeting had been set up with the Non-Executive Board Members to discuss positive messages around this issue.

Mr Carey assured the Committee that Corporate Communication had commenced working on planning publicity to highlight positive messages to public and staff. An article will appear in next Tuesday’s Team Brief.

The Committee noted the report and progress being made and agreed that Healthcare Associated Infection will remain as a standing item.

9 NEW BUSINESS: 9.1 Non-Medical Prescribing It was agreed that due to the limited timescale this item would be included on the next Clinical Governance Committee meeting on the 14th May 2010.

9 9.2 Maternity Review Update Mrs Smith presented to the Committee for information an update on Maternity Service Review in NHS Grampian.

Mrs Smith referred to the paper and highlighted the key points as detailed below:

 The revised national direction framework 2002 has been revised and will be re-launched in May 2010.

 There had been a recent upward trend in births in Grampian and likely to continue. Health Intelligence will be looking into this to see how much this was an issue or perception.

 A leadership group had been established including representatives from across the system with support from the Continuous Service Improvement Team.

 The leadership group had developed a CSI Project Proposal Document adopted by the CSI Leadership Group. A Value Stream Analysis (VSA) session will be arranged in May 2010.

 Scope of the review was to recognise interface issues as a priority looking at maternity services with links to the Fertility Centre.

The Maternity Service Review was at a very early stage but felt it was important NHS Grampian work to present to the Committee.

The Committee noted the paper and the plans being made.

10 SECTOR/SERVICE REPORTS The Committee thanked those concerned for all the hard work that had been put in to producing these reports and commended the Sectors/Service areas on all the Areas of Achievement and good practice that were noted in the reports.

The Committee noted the following reports that had been submitted by the Sectors and Service areas:

10.1 Aberdeenshire Due to the weather Dr Gatenby was unable to attend the Clinical Governance Committee meeting.

The Committee asked for an update on item 3a) reported under progress against areas of concern previously reported where a root cause analysis was undertaken. Mrs Smith informed the Committee that actions were being taken forward from the recommendations from the Root Cause Analysis and both Mrs Smith and Mr J Stuart, General Manager had met with the family.

10.2 Acute Mr O’Kelly brought to the Committee’s attention the new areas of concern under Item 2c) Blood transfusion incident when the correct protocols were not used, this continues to be closely monitored. 10 Mr O’Kelly highlighted the items from the report under progress against areas of concern previously reported; Item 3b) Emergency planning preparedness, not all areas had developed action plans, the Acute Sector senior management team were working to ensure preparedness and arrange further training days. 3c) Bed availability and staff shortages, this was being kept under active review. 3d) Variation of protocols and policies for the prevention and management of Deep Vein Thrombosis (DVT). Work was progressing and nearing the final stages to streamline across NHS Grampian to ensure an organisation wide policy. 3j) C. Difficile outbreak at ARI, work had been undertaken around antimicrobial prescribing practices within ARI and had resulted in a downward trend in the use of the 4C’s antibiotics.

Mr O’Kelly brought to the Committee’s attention the Area of achievement/good practice; The NHS Grampian Consent policy had now been approved and will be disseminated widely across the organisation, this is a single policy for all specialities.

10.3 Moray Dr Bearn brought to the Committee’s attention the new area of concern against NHS Grampian Clinical Governance work plan under item 1b) NES were unable to fill some junior doctor rotation posts, this issue was being managed but continues to be an on-going concern.

Dr Bearn also highlighted the progress against areas of concern previously reported under item 3a) Prophylaxis and D Dimer, a policy is nearing completion and will be rolled out across NHS Grampian to ensure compliance amongst medical and nursing staff.

Dr Bearn informed the Committee that Dr Gray’s Hospital were to be inspected by the Healthcare Environment Inspectorate on the 7th and 8th April 2010 and preparations for this were progressing well.

Dr Bearn highlighted to the Committee the area of achievement/good practice.

Dr Dijkhuizen raised the issue of staffing difficulties for junior doctors covering rotations and A&E consultants at Dr Gray’s Hospital. Dr Dijkhuizen highlighted that these were issues for North of Scotland and national work was being undertaken to look at initiatives to address.

10.4 Mental Health and Learning Disability Service Dr Callender referred to the item under New areas of concern under Items; 2a) Two wards closed due to norovirus, a group was progressing actions based on findings. Item 2e) looking at environmental changes due to an attempted suicide in a dormitory of adult admission ward; a risk assessment of hidden areas was carried in 2009 this will be reviewed based on the local investigation.

Dr Callender highlighted to the Committee the Areas of achievement/good practice; Patient Safety Walk rounds had been planned within Mental Health Services and commented that he felt the methodology used was not so applicable to Mental Health Services.

11 Dr Callender referred to the report and brought to the Committee’s attention item 6, “Issues to note”; Scottish ECT [Electro Convulsive Therapy] Accreditation (SEAN) which was carried out on 29th January 2010. Dr Callender informed the Committee that two of the Type 1 (mandatory criteria) had not been met. Measures were being taken to address these failures and Dr Dijkhuizen had indicated this in a letter to SEAN. The General Manager was liaising with ARI re anaesthetic shortfall and long term solutions.

10.5 Aberdeen City Mr Poon brought to the Committee’s attention that there was no new areas of concern reported.

Mr Poon highlighted the items from the report under progress against areas of concern previously reported, Item 3a) The hand hygiene audits at the Links Unit were 95% compliant. Discussions were underway to undertake an audit of compliance with the falls guidelines within Intermediate Care. Item 3b) Infant death in Aberdeen City; the date of the court case will be on the 28th June 2010.

Mr Poon highlighted to the Committee the area of achievement/good practice.

Mr Poon referred to the additional items reported and informed the Committee that Medication Safety and Healthcare Associated Infection were items that were regularly discussed at the Aberdeen City Clinical Governance Group and were included on the Sector Newsletter.

10.6 Public Health Directorate There was no representative from the Public Health Directorate.

10.7 Out of Hours Service Report Dr Dijkhuizen referred to the Out of Hours Service Report and highlighted that there were a number of areas of concern previously reported which were being managed; Item 3a) high patient demand and concern re staffing, further recruitment drive for salaried doctors and paramedic/nurse practitioners.

Dr Dijkhuizen highlighted to the Committee the area of achievement/good practice

10.8 Combined Child Health Service (CCHS) The Committee highlighted item 3c) under progress against areas of concern previously reported. The level of risk had not changed since first being reported. Mr Carey agreed to follow-up this item with the management team to provide the Committee with an update on what was being undertaken to resolve this issue.

11 FEEDBACK SERVICE: 11.1 Joint Reporting of Incidents and Feedback Mrs Oldroyd presented a paper to the Committee on Joint Reporting of Incidents and Feedback and provided some information that previously

12 incidents and feedback had been reported separately to the Clinical Governance Committee. The Datix Incident reporting module had been upgraded and now enables the Feedback Service access to both approved and unapproved incidents on the system and allows searching for related incidents when a complaint was received.

Mrs Oldroyd referred to the two options proposed in the report: Option 1: Reporting incidents and feedback side by side by sector.

Option 2: Case study style reports of incidents and feedback which are known to be correct.

Mrs Oldroyd highlighted that joint reporting of incidents and feedback may be a mechanism for early intervention for any quality and safety issues.

The Chief Executive thanked Mrs Oldroyd for presenting this paper to the Clinical Governance Committee and commented that this required a management decision around the options and to feedback to the Committee on the decision made.

11.2 Feedback Service Report for 1 October to 31 December 2009 and Ombudsman update Mrs Oldroyd, Nurse Consultant Patient Safety and Experience and Manager of Feedback Service provided the Committee with an update as detailed in the Feedback Report.

In the last quarter a further breakdown of information was given about complaints relating to staff attitude and behaviour. This report looks at the category “Environment/Domestic” and picks out the top six subjects of complaint; Parking, Cleanliness, Property/Expenses, Privacy/Dignity, HAI and Catering. Mrs Oldroyd referred to this chart which highlighted that the highest number of complaints continues to be around car parking for this category.

Mrs Oldroyd highlighted the key points:  The number of re-opened complaints by sector had fallen significantly this quarter. The re-opened complaints attributable to the Acute sector had increased, work was being undertaken to investigate this increase.

 A number of complainants remain dissatisfied with the formal response to their complaint and contact the Feedback Service with their outstanding concerns. At this point, a meeting was usually offered to try and resolve complainants’ issues. Despite this there was a downward trend in this percentage of complaints re-opened.

 Increased number of compliments and other feedback received this quarter.

 Mrs Oldroyd highlighted the positive outcomes from the previous quarter.

 Administration support for the Feedback Service had been successfully appointed.

13  Feedback Service delivered a session on “Complaining about Complaints” but unfortunately the session was poorly attended.

 Children’s feedback card was being piloted at Royal Aberdeen Children’s Hospital.

 There were no reported on cases closed by the Ombudsman in the period

Mrs Oldroyd informed the Committee that she had been invited to attend a meeting to discuss how visually impaired patients can feedback complaints or compliments to NHS Grampian.

The Committee asked for the word “allegedly” to be included in the Issue column of the Complaints to Ombudsman – January 2010 report to case number 902396.

The Committee noted the report and agreed the recommendations. 11.3 Claims Report for 1 October to 31 December 2009 Mr Jackson referred to his paper and provided detail around a couple of cases.

Mr Jackson informed the Committee that for the next Clinical Governance Committee there will be a more detailed report highlighting the learning points.

The Committee noted and agreed the recommendation in the report submitted by Mr A Jackson, Legal Advisor.

12 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 Quality Improvement Scotland had altered their assessment scale and all local reports were re-assessed against the revised scale. NHS Grampian had received the final report and achieved a positive result.

Ms Robbins suggested to Committee members to invite the Clinical Leads for Food, Fluid and Nutritional Care and Anaesthetics to report on the outcomes of the respective peer reviews.

JAG Endoscopy Units: Pre-JAG was a national UK assessment process. Visits had been scheduled for Dr Gray’s Hospital (24th February 2010) and Aberdeen Royal Infirmary (25th February 2010), and no date scheduled for Aberdeenshire Community Hospitals.

Sexual Health: The self assessment paperwork had been received from NHS Quality Improvement Scotland. There was an existing group focussing on these standards with a great deal of progress being made.

Clinical Governance & Risk Management: Staff in the Clinical Governance & Risk Management Unit met to explore how we maintain the level that was achieved and to continue with improvements of systems and processes for the Clinical Governance & Risk Management Standards. NHS Grampian took part in an MSc 14 project and was used as a case study NHS Board - The Role of Clinical Governance & Risk Management review in promoting continuous improvement.

Healthcare Environment Inspectorate: This was discussed under the Healthcare Associated Infection update.

Other areas of work Interventional procedures NHS QIS were exploring ways of assuring the SEHD re the use of Interventional Procedures. These were issued by NICE and where a service was carrying out these procedures they should be using the guidance. This work was under development but may have implications for NHS Grampian.

NHS QIS Renal Patient Experience Survey A Scottish Renal Patient Experience Survey report had been published

The Committee agreed that the Clinical Leads for Food, Fluid and Nutritional Care, Anaesthetics and Pre-JAG were to be invited to report to the Clinical Governance Committee.

The Committee noted and agreed the recommendations in the paper.

13 ITEMS FOR NOTING AND INFORMATION Committee members were advised that copies of any documents listed could be obtained by contacting Mrs Fiona Shepherd.

14 AOCB There was no AOCB.

15 REPORTING TO THE BOARD The Chairman agreed to report to the Board on the following items: 1. Surgical Profile 2. Patient Safety 3. Medication Safety

16 DATE AND TIME OF NEXT MEETING Friday 14th May 2010 in the Conference Room, Summerfield House from 9.30- 12.30pm. The Development Session on Child Protection will follow on after the meeting from 12.30-4.00pm.

17 A Development Session followed on from the meeting - Follow-up on “Asking Challenging Questions”.