NHS FIFE CLINICAL GOVERNACE COMMITTEE 04 March 2020, 14:00 to 17:00 STAFF CLUB, VHK Agenda 1 APOLOGIES FOR ABSENCE Wilma Brown, Dona Milne (Rep Dr Hamlet & Emma O'Keefe), Janette Owens, Helen Buchanan, Morag Olsen (Rep Andy MacKay), Scott Garden (Debs Stevenson in attendance), Susan Fraser 2 DECLARATIONS OF MEMBERS' INTERESTS 3 MINUTES OF PREVIOUS MEETING HELD ON 16 JANUARY 2020 (attached) Item 3 Unconfirmed Notes 160120 GM.pdf (12 pages) 4 ACTION LIST (attached) Item 4 TABLE OF ACTION MARCH 2020.pdf (3 pages) 5 MATTERS ARISING 5.1 Surgical Site Infection (SSI) Update ‐ Obstetrics Improvement & New Pathway (attached) Chris McKenna/Helen Buchanan Item 5.1 CGC_SBAR_Maternity and Obstetrics_Feb (1 pages) 2020.pdf Item 5.1 CGC_Maternity and Obstetric Update_Feb (8 pages) 2020_final 1.pdf 5.2 Alcohol & Drug Partnership Report (attached) Dona Milne Item 5.2 SBAR Clinical Governance ADP March 2020 (5 pages) final.pdf Item 5.2 18 10 19 ADP Report V01 0 FINAL.pdf (61 pages) 5.3 Drug Related Deaths Update (attached)) Dona Milne Item 5.3 Clinical Governance DRD SBAR March 2020 (4 pages) final.pdf 5.4 Prescribed High Risk Medicines (attached) Scott Garden Item 5.4 ‐ NHS Fife CGC Drug Related Deaths ‐ High (7 pages) Risk Medicines paper 040320.pdf 5.5 Organisational Resilience Standards Update (attached) Dona Milne Item 5.5 SBAR Clinical Governance ‐ Resilence (2 pages) Standards April submission to SGHRU March 2020 final.pdf Item 5.5. NHS Fife Resilience Standards Action Plan (17 pages) February 2020 for CGC.pdf 6 REQUESTED REPORT 6.1 Coronavirus Update (attached) Dona Milne Item 6.1 COVID‐19 SBAR NHSFCGC_040320_v2.pdf (6 pages) 6.2 NHS Fife Digital & Information Strategy (attached) Chris McKenna Item 6.2 SBAR Digital and Information Strategy.pdf (2 pages) Item 6.2 NHS Fife ‐ Digital and Information Strategy (37 pages) (1).pdf 7 TRANSFORMATION / REDESIGN / CLINICAL STRATEGY 7.1 Update from Integrated Transformation Board (attached) Jim Crichton Item 7.1 SBAR CGC Transformation Programme (4 pages) Governance Update ‐ Final.pdf Item 7.1 Update Report Medicines Efficiencies (2 pages) Programme Status Report December 2019.pdf 7.2 Acute Transformation (verbal) Morag Olsen 7.3 Community Hospital Redesign (verbal) Nicky Connor 7.4 Clinical Strategy Update (attached) Susan Fraser Item 7.4 SBAR CGC Clinical Strategy revision (2 pages) 04032019.pdf 8 QUALITY, PLANNING AND PERFORMANCE 8.1 Integrated Performance & Quality Report (attached) Susan Fraser Item 8.1SBAR for IPQR Standing Committees.pdf (3 pages) Item 8.1 IPQR Feb 2020.pdf (43 pages) 8.2 Winter Performance Report (attached) Nicky Connor/Morag Olsen Item 8.2 SBAR Winter Report.pdf (3 pages) Item 8.2 Winter Planning Performance Summary Jan (15 pages) v0 2.pdf 9 GOVERNANCE 9.1 Review of Fife Health & Social Care Integration Scheme (verbal) Nicky Connor 9.2 Board Assurance Framework ‐ Quality & Safety (attached) Chris McKenna/Helen Buchanan Item 9.2 SBAR Report BAF Quality and Safety (3 pages) NHSFCGC 040320 V1 0.pdf Item 9.2 NHS Fife Board Assurance Framework (BAF) (1 pages) Quality and Safety V19 200220.pdf Item 9.2 BAF Risks ‐ Quality and Safety ‐ Linked (3 pages) Operational Risks at 200220.pdf 9.3 Board Assurance Framework ‐ Strategic Planning (attached) Susan Fraser Item 9.3 SBAR CGC BAF 5 04032020.pdf (3 pages) Item 9.3 NHS Fife Board Assurance Framework (BAF) (1 pages) 040320 ‐ Strategic Planning.pdf 9.4 Board Assurance Framework ‐ eHealth (attached) Chris McKenna Item 9.4 SBAR Board Assurance Framework ehealth (3 pages) for CGC 100220.pdf Item 9.4 BAF Risks ‐ eHealth ‐ Linked Operational (9 pages) Risks as at 100220.pdf Item 9.4 NHS Fife Board Assurance Framework (BAF) (1 pages) V3 0 100220 ‐ eHealth.pdf 9.5 eHealth Governance Review (attached) Chris McKenna Item 9.5 SBAR eHealth Governance Review CCG.pdf (3 pages) Item 9.5 SBAR Appendicies ‐ eHealth Current (1 pages) Governance.pdf 9.6 Committee Self Assessment Report (attached) Gillian MacIntosh Item 9.6‐ SBAR Committee SA report CG.pdf (8 pages) 9.7 Review of Committee's Terms of Reference (attached) Gillian MacIntosh Item 9.7 ‐ CG ToR.pdf (6 pages) 9.8 Annual Workplan 2020/21 (attached) Helen Woodburn Item 9.8 190220SBARworkplanV1 0.pdf (2 pages) Item 9.8Annual Workplan 2020 ‐21.pdf (2 pages) 9.9 Annual Accounts ‐ Progress Update on Audit Recommendations (attached) Gillian MacIntosh Item 9.9 ‐ SBAR cover Annual Audit Report (2 pages) Recommendations.pdf Item 9.9‐ Annual Audit Report Recommendations (12 pages) Update March 2020 FINAL.pdf 9.10 HAIRT Report (attached) Helen Buchanan Item 9.10 HAIRT Report December update.pdf (19 pages) 10 LINKED COMMITTEES 10.1 Acute Services Division Clinical Governance Committee ‐ 22 January 2020 c/f 7 May 2020 10.2 Area Clinical Forum ‐ 6 February 2020 (attached) Item 10.2 Cover sheet for Minutes NHSFCGC.pdf (1 pages) Item 10.2 ACF Development Session 20200206.pdf (1 pages) 10.3 Area Drugs & Therapeutics Committee ‐ 19 February 2020 c/f 7 May 2020 10.4 HSCP Clinical and Care Governance Committee ‐ 8 November 2018 & 10 January & (attached) 2020 Item 10.4 Cover sheet for Minutes NHSFCGC HSCP (2 pages) CCG Fri 8th Nov.pdf Item 10.4 HSCP CCGC Confirmed Minute 081119.pdf (13 pages) Item 10.4 Cover sheet for Minutes NHSFCGC HSCP (2 pages) CCG Fri 10th Jan.pdf Item 10.4 HSCP CCGC Unconfirmed Minute 10 01 (22 pages) 20.pdf 10.5 Clinical Governance Oversight Group ‐ 23 January 2020 (attached) Item 10.5 Cover sheet NHS Fife Clinical Governance (2 pages) Oversight Group minutes 23 01 20.pdf Item 10.5 Unconfirmed Meeting Note of NHS Fife (5 pages) Clinical Governance Oversight Group 23 01 2020.pdf 10.6 Fife Research Committee ‐ 9 January 2020 (attached) Item 10.6 Cover sheet for Minutes NHSFCGC.pdf (2 pages) Item 10.6 Research Governance Group minutes.pdf (4 pages) 10.7 Integrated Joint Board ‐ 6 December 2019 (attached) Item 10.7 Draft IJB Minute 06 12 19 ‐ (8 pages) Unconfirmed.pdf 10.8 Infection Control Committee ‐ 5 February 2020 (attached) Item 10.8 Infection Control Committee minutes 04 (8 pages) 12 19.pdf 10.9 Radiation Protection Committee (attached)) Item 10.9 Cover sheet RPC October 2019.pdf (1 pages) Item 10.9 MINUTES RPC OCTOBER 2019.pdf (3 pages) 10.10 Resilience Forum ‐ 15 January (no meeting) & 5 February 2020 (Cancelled) 10.11 eHealth Board ‐ 21 January 2020 (attached) Item 10.11 Cover sheet for Minutes eHealth Board (1 pages) 200304 NHSFCGC.pdf Item 10.11 eHealth Board Minutes 21 01 20 v0 4.pdf (6 pages) 10.12 Information Governance & Security Group ‐ 16 January 2020 (attached) Item 10.12Cover sheet for Minutes NHSFCGC.pdf (1 pages) Item 10.12 CONFIRMED IGS Minute ‐ 12 11 19.pdf (7 pages) 10.13 Integrated Transformation Board ‐ 19 November 2019 & 13 February 2020 (attached) Item 10.13 Cover sheet for Minutes ITB 19 11 2019 (1 pages) NHSFCGC.pdf Item 10.13 ITB Minutes 19 11 19.pdf (4 pages) Item 10.13Cover sheet for Minutes ITB 13 02 2020 (1 pages) NHSFCGC.pdf Item 10.13 ITB Minutes 13 02 20202 ‐ CP (6 pages) comments.pdf 10.14 Health & Safety Sub Committee ‐ 13 December 2019 (attached) Item 10.14 2020‐02‐19 H+S Governance Group CGC (1 pages) return.pdf Item 10.14 2020‐02‐21 Unconfirmed Minutes Dec (3 pages) Meeting.pdf 11 ITEMS FOR NOTING 11.1 CMO Taskforce Board Specific Update Report (attached) Chris McKenna/Helen Buchanan Item 11.1 Board Chair Update Report Fife.pdf (9 pages) 12 ISSUES TO BE HIGHLIGHTED TO THE BOARD 12.1 To the Board in the IPQR and Chair's comments (verbal) 13 AOCB (verbal) 14 DATE OF NEXT MEETING Thursday 7 May 2020 at 2pm in the Staff Club UNCONFIRMED MINUTE OF NHS FIFE CLINICAL GOVERNANCE COMMITTEE HELD ON THURSDAY 16 JANUARY 2020 AT 2PM IN THE STAFF CLUB, VHK Present: Dr Les Bisset, Chair Martin Black, Non Exec Member Sinead Braiden, Non Exec Member Cllr David Graham, Non Exec Member Rona Laing, Non Exec Member Margaret Wells, Non Exec Member Wilma Brown, APF Representative Janette Owens, ACF Representative John Stobbs, Patient Representative Helen Buchanan, Director of Nursing Dona Milne, Director of Public Health Dr Chris McKenna, Medical Director Carol Potter, Director of Finance (deputising for Paul Hawkins) In Attendance: Dr Rob Cargill, AMD, ASD Nicky Connor, Director of H&SCP Susan Fraser, Associate Director of Planning Scott Garden, Director of Pharmacy (until & Performance 4pm) Gillian MacIntosh, Board Secretary (until 3pm) Morag Olsen, Interim COO ASD Helen Woodburn, Quality & Clinical Gov Lead Catriona Dziech, Note Taker MINUTE REF ITEM ACTION 001/20 APOLOGIES FOR ABSENCE Apologies were received from member Paul Hawkins and attendee Linda Douglas. 002/20 DECLARATIONS OF MEMBERS’ INTERESTS There were no declarations of interest. 003/20 MINUTES OF PREVIOUS MEETING HELD ON 6 NOVEMBER 2019 The notes of the meeting held on 6 November 2019 were approved. 004/20 ACTION LIST All outstanding actions were updated on the separate rolling Action List. 005/20 MATTERS ARISING 5.1 Surgical Site Infection (SSI) Update – Obstetrics Improvement Plan Dr McKenna advised this update related to the wider Obstetric Improvement Plan and reducing SSIs was part of that larger programme of work. Dr McKenna had hoped to be able to provide the Committee with a more detailed update but this was not available. This therefore remains an ongoing action. Issue: V1 Date: January 2020 Originator: Catriona Dziech Page 1 of 12 1/12 1/430 UNCONFIRMED Helen Buchanan advised that the new methodology was being applied and, under this, there had been a substantial reduction in SSIs over the last two quarters.