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Bundle Quality, Safety and Experience Committee 17 December 2019 Bundle Quality, Safety and Experience Committee 17 December 2019 Agenda attachments 00 - Agenda Dec 2019 - v3.docx 1 STANDING ITEMS 1.1 Welcome and Introductions Susan Elsmore 1.2 Apologies for Absence Susan Elsmore 1.3 Declarations of Interest Susan Elsmore 1.4 Minutes of the Committee Meeting held on 17 September 2019 and 15 October 2019 Susan Elsmore 1.4 - QSE Public Mins 17.09.19 NF Final.docx 1.4.1 - QSE Mins 15.10.19 v2 - AF.NF Final.docx 1.5 Action Log - 17 September 2019 and 15 October 2019 Susan Elsmore 1.5 Action Log Sep 2019.docx 1.6 Chair's Action taken since last meeting Susan Elsmore 1.7 Clinical Board Assurance Report: Clinical Diagnostics and Therapeutics Clinical Board Aled Roberts 1.7 - CD&T Board Assurance Report.pdf 2 PATIENT STORY 3 ITEMS FOR REVIEW AND ASSURANCE 3.1 Healthcare Standards Self-Assessment Plan and Progress Update Carol Evans 3.1 -Health and Care standards Dec 2019_v 4 FINAL.docx 3.1.1 - Appendix 1 - ISN 2019 003 - Resuscitation trolley checks.pdf 3.1.2 - Appendix 2 H&CS_Dec_2019 v3 FINAL.docx 3.2 Point of Care Testing Stuart Walker 3.2 - QSE POCT SBAR 171219 (002) Final.docx 3.3 Update on Stroke Rehabilitation and Model Workforce Verbal - Fiona Jenkins 3.4 Local Clinical Audit Plan Update Stuart Walker 3.4 - Clinical Audit Plan Update -18.12.18.docx 3.4.1 - Local Clinial Audit appendix 1.xlsx 3.5 Cancer Peer Review Stuart Walker 3.6 - Peer Review report for QSE Dec 19.docx 3.6 Internal Inspections Ruth Walker 3.6 - Internal Inspections QSE.docx 3.7 Patient Notification Exercises in Cardiff and Vale of Glamorgan Populations: Hepatitis C Virus Infection Re- engagement Project 3.7 - Hepatitis C Patient Re-engagement QSE Paper V1 20.11.19.docx 3.7.1 - Fact Sheet final.docx 4 ITEMS FOR APPROVAL / RATIFICATION 4.1 Policies: 4.1.1 Consent to Examination or Treatment Policy Stuart Walker 4.1.1 - SBAR Consent to treatment 1119.docx 4.1.1b - Consent Policy final 201119 v2.docx 4.1.1c - EHIA Consent Policy final 1119.docx 4.1.2 Management of Throat Pack Policy and Procedure Stuart Walker 4.1.2 - Management of a Throat Pack Report.docx 4.1.2b - Management of a throat pack policy and procedure.docx 4.1.2c - Management of a throat pack EQIA.docx 4.1.3 Child Abduction Policy Ruth Walker 4.1.3 - SBARchildabductionpolicy.docx 4.1.3a - ChildabudctionpolicyAMMENDED.docx 4.1.4 Update of Healthy Eating Standards for Hospital Restaurant and Retail Outlets Fiona Kinghorn 4.1.4 - UHB Restaurant Retail Food Standards V1 FK.DOCX 4.1.4b - Refreshed Hospital Restaurant Food Standards Dec 2.docx 5 ITEMS FOR NOTING 5.1 NICE Guidance Update Stuart Walker 5.1 - NICE QSE December 2019 v1.docx 5.2 Health Inspectorate Wales Activity Overview Carol Evans 5.2 - HIW Activity update December 2019 -QSE v2.docx 5.2.1 - Appendix 1 - ISN 2019 003 - Resuscitation trolley checks.pdf 5.2.2 - Appendix 2 - 19065 - OCS - Stroke Rehabilitation Centre at UHL - Improvement Plan 30_...docx 5.3 Health Inspectorate Wales Primary Care Contractors Carol Evans 5.3 - HIW SBAR -November 2019 v2.docx 5.3.1 - HIW Nov 2019 Appendix 1 GMS.docx 5.3.2 - HIW Nov 2019 Appendix 2 GDS v2.docx 5.4 Minutes from Clinical Board Quality, Safety and Experience Sub Committee - Exceptional Items to be raised by the Assistant Director, Patient Safety and Quality Carol Evans 5.4.1 Children and Women Clinical Board Steve Curry 5.4.1 - Children Women QSPE Minutes 28.05.19.docx 5.4.1a - Children Women QSPE Minutes 25.06.19.docx 5.4.1b - CW QSPE Minutes 24.09.19.docx 5.4.2 Clinical Diagnostics and Therapeutics Clinical Board Steve Curry 5.4.2 - CD&T - Minutes 14.8.19.docx 5.4.2a - CD&T - Minutes 11.9.19.docx 5.4.2b - CD&T Minutes 9.10.19.docx 5.4.3 Medicine Clinical Board Steve Curry 5.4.3 - Medicine Clinical Board QSE Minutes 20.06.19.doc 5.4.3a - MCB QSE Minutes 18.07.19.doc 5.4.3b - MCB QSE Minutes 19.09.19.doc 5.4.3c - MCB QSE Minutes 23.10.19.doc 5.4.4 Mental Health Clinical Board Steve Curry 5.4.4 - MH 18 July 2019 Minutes.doc 5.4.5 Primary, Community and Intermediate Care Clinical Board Steve Curry 5.4.5 - PCIC Group mins July 2019 KJ.docx 5.4.5b - PCIC mins Nov 2019.docx 5.4.6 Specialist Services Clinical Board Steve Curry 5.4.6 - Specialist Services Minutes QSE 27.06.19.docx 5.4.6a - Specialist Services Minutes QSE 18 07 19 vn 2.docx 5.4.7 Surgery Clinical Board Steve Curry 5.4.7 - Surgery Q&S Minutes 2019 07 30.docx 5.4.7a - Surgery CB Mins 10.09.19.docx 6 ITEMS TO BRING TO THE ATTENTION OF THE BOARD / OTHER COMMITTEES Susan Elsmore 7 Review of the Meeting Susan Elsmore 8 Date and Time of Next Committee Meeting: 18 February 2020 at 9.00am Coed y Bwl, Ground Floor, Woodland House, Heath Agenda attachments 1 00 - Agenda Dec 2019 - v3.docx Quality, Safety & Experience Committee Tuesday, 17 December 2019 at 9.00am Coed y Bwl, Woodland House AGENDA 1. Standing Items 1.1 Welcome & Introductions Susan Elsmore 1.2 Apologies for Absence Susan Elsmore 1.3 Declarations of Interest Susan Elsmore 1.4 Minutes of the Committee Meeting held on 17 September 2019 and 15 Susan Elsmore October 2019 1.5 Action Log from 17 September 2019 and 15 October 2019 Susan Elsmore 1.6 Chairs Action taken since last meeting Susan Elsmore 1.7 Clinical Board Assurance Report: Clinical Diagnostics and Mike Bourne / Therapeutics Clinical Board Matthew Temby 2. Patient Story: 3. Items for Review & Assurance 3.1 Health Care Standards Self-Assessment Plan & Progress Update Carol Evans 3.2 Point of Care Testing Stuart Walker 3.3 Update on Stroke Rehabilitation and Model Workforce Fiona Jenkins Verbal 3.4 Local Clinical Audit Plan Update Stuart Walker 3.5 Cancer Peer Review Stuart Walker 3.6 Internal Inspections Ruth Walker 3.7 Patient Notification Exercises in Cardiff and Vale of Glamorgan Fiona Kinghorn Populations: Hepatitis C Virus Infection Re-Engagement Project 4. Items for Approval / Ratification 4.1 Policies: 1. Consent to Examination or Treatment Policy Stuart Walker 2. Management of Throat Pack Policy and Procedure Stuart Walker 3. Child Abduction Policy Ruth Walker 4. Update of Healthy Eating Standards for Hospital Restaurant Fiona Kinghorn and Retail Outlets 5. Items for Noting & Information 5.1 NICE Guidance Update Stuart Walker 5.2 Health Inspectorate Wales Activity Overview Carol Evans 5.3 Health Inspectorate Wales Primary Care Contractors Carol Evans 5.4 Minutes from Clinical Board Quality Safety and Experience Sub Committees – Exceptional Items to be raised by the Assistant Director, Carol Evans Patient Safety and Quality 5.4.1 Children and Women – 28.05.19, 25.06.19 and 24.09.19 Steve Curry 5.4.2 Clinical Diagnostics and Therapeutics – 14.8.19, 11.09.19 and 9.10.19 5.4.3 Medicine – 20.06.19, 18.07.19, 19.09.19 and 23.10.19 5.4.4 Mental Health – 18.7.19 5.4.5 Primary, Community and Intermediate Care – 17.07.19 and 12.11.19 5.4.6 Specialist Services – 27.06.19 and 18.07.19 5.4.7 Surgery – 30.07.19 and 10.09.19 6. Items to bring to the attention of the Board/Committee Susan Elsmore 7. Review of the Meeting Susan Elsmore 8. Date and time of next Meeting: Susan Elsmore 18 February 2020 at 9.00am, Coed y Bwl, Ground Floor, Woodland House, Heath 1.4 Minutes of the Committee Meeting held on 17 September 2019 and 15 October 2019 1 1.4 - QSE Public Mins 17.09.19 NF Final.docx UNCONFIRMED MINUTES OF QUALITY, SAFETY AND EXPERIENCE COMMITTEE HELD ON TUESDAY, 17 SEPTEMBER 2019 COED Y BWL, WOODLAND HOUSE, HEATH, CARDIFF CF14 4TT Present: Susan Elsmore SE Committee Chair and Independent Member – Local Government Gary Baxter GB Independent Member - University Michael Imperato MI Independent Member – Legal Dawn Ward DW Independent Member – Trade Union In attendance: Steve Curry SC Chief Operating Officer Carol Evans CE Assistant Director of Patient Safety and Quality Nicola Foreman NF Director of Corporate Governance Suzanne Hardacre SH Head of Midwifery and Gynaecology Nursing Cath Heath CH Nurse Director, Children and Women Angela Hughes AH Assistant Director of Patient Experience Fiona Jenkins FJ Executive Director of Therapies and Health Science Fiona Kinghorn Executive Director of Public Health Meriel Jennings MJ Clinical Board Director, Children and Women Christopher Lewis CL Deputy Director of Finance Paul Rogers PR Directorate Manager for the Artificial Limb and Appliances Service (ALAS) Ruth Walker RW Executive Nurse Director Stuart Walker SW Executive Medical Director Glynis Mulford GM Secretariat Observers: Mandy Rayani Hywel Dda University Health Board Joanne Wilson Hywel Dda University Health Board Apologies: Robert Chadwick RC Executive Director of Finance Steve Allen SA Community Health Council QSE 19/09/001 WELCOME AND INTRODUCTIONS ACTION The Chair welcomed everyone to the meeting including colleagues from the Children and Women’s Clinical Board. A special welcome was also extended to Joanne Wilson, Director of Corporate Governance and Mandy Rayani, Executive Nurse Director from Hywel Dda University Health Board who observed the meeting. QSE 19/09/002 APOLOGIES FOR ABSENCE Apologies for absence were noted.
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