confirmed - fifeadmin.fifedirect.org.uk/weborgs/nhs/uploadfiles/...150217… · web...

$: CONFIRMED - Fifeadmin.fifedirect.org.uk/weborgs/nhs/uploadfiles/...150217… · Web viewCONFIRMED. T:\Medical Directorate Fife & PCT PA\Catriona\Clinical Governance Committee\Notes\2017\150217.docx$
CONFIRMED

MINUTE OF NHS FIFE CLINICAL GOVERNANCE COMMITTEEHELD ON WEDNESDAY 15 FEBRUARY 2016 AT 9.30AM

IN THE STAFF CLUB AT VHK

Present:Dr L Bisset, Chair Moira Adams, Non Executive Committee MemberRona Laing, Non Executive Committee MemberSimon Little, Non Executive Committee MemberJanette Owens, ACF Representative Alison Rooney, Non Executive Committee MemberGillian Tait, APF Representative

In Attendance: Dr R Cargill, Associate Medical Director, Acute Services DivisionDr F Elliot, Medical Director NHS Fife Gillian Fenton (for Michael Kellet)Dr M Hannah, Director of Public HealthPaul Hawkins, Chief ExecutiveTricia Marwick, Chair, NHS Fife (observer)Scott McLean, Director of Acute ServicesHelen Woodburn, Quality & Clinical Governance LeadHelen Wright, Nurse Director NHS Fife (now Helen Wright (HWr)Catriona Dziech, Note Taker

MINUTEREF

ITEM ACTION

001/17 CHAIRPERSON’S WELCOME AND OPENING REMARKS

Dr Bisset welcomed everyone to the meeting especially Tricia Marwick, new Chair of NHS Fife, who was attending the Committee today as an observer.

002/17 DECLARATION OF MEMBERS’ INTERESTS

There were no declarations of interest.

003/17 APOLOGIES FOR ABSENCEMichael Kellet, Dr McCallum, Elizabeth Muir

/tt/file_convert/5aa028af7f8b9a89178dab1c/document.docx Issue: V1 Date: February 2017Originator: Catriona Dziech Page 1 of 14

004/17 MINUTES OF PREVIOUS MEETING HELD ON 14 DECEMBER 2016

The minutes of the meeting held on 14 December 2016 were confirmed subject to the following amendments:

Minute Ref 67/16 – Apologies for AbsenceRemove the word “on” preceding passed.

Minute Ref 070/16 – Medical / Nurse Director Reportsa) Draft Quality ReportPage 5 – first paragraph – second line – replace “sour” with “staff”

005/17 MATTERS ARISING Outstanding Actions from Action List

Item 13NHS Fife Prevention & Control of Infection Implementation Framework Update

To be discussed under Main Agenda Item 8 (a).

Item 21NHS Fife Clinical & Care Governance Strategy

To be discussed under Main Agenda Item 8 (b).

Item 27Management of Adverse Events Improvement Plan Update

To be discussed under Main Agenda Item 8 (c).

Item 59Draft Quality Report

To be discussed under Main Agenda Item 6 (a).


005/17Item 61Working with the Pharmaceutical Industry & Healthcare Equipment Suppliers – Guidance for NHS Staff

Dr Elliot advised this item was being discussed at the ADTC meeting on 15 February 2017 and would be considered further at NHSFCGC in April 2017.

FME

Item 63Novel Procedures

Dr Elliot confirmed this item had been discussed at EDG and would be considered at the NHSFCGC in April 2017.

FME

Item 64MRSA / SABs

It was agreed this item could be removed from the Action List meantime. Scott McLean and Dr Elliot would agree a date for the next update to the NHSFCGC Committee.

SMcL/ FME

Item 65Paediatric Drug Trolley / Medication Safety Action Plan

To be discussed under Main Agenda Item 8 (e).

Item 79Research & Development Annual Report

Dr Elliot confirmed the data for Alison Rooney was being worked on.

FME

Item 80ASD Clinical Governance ToR

To be discussed under Main Agenda Item 8 (f).

There were no other Matters Arising from the Action List but it was agreed it would be helpful to have some comments in the “Progress” column of the Action List.

CD

006/17 MEDICAL / NURSE DIRECTOR REPORTS


Quality Report

Dr Elliot advised this iteration of the Quality Report clarifies comments previously made by Non Executives. The data for the report is being updated to ensure it can provide assurance to the Committee. An Executive Summary will then go to the Board.

Following lengthy discussion the following actions were agreed:

FME/HWo

Narrative to explain the highlights would be helpful.

Correct typos on P18 and change repetitive narrative.

The narrative in the “Key Issues” Section could be expanded to ensure Committee members understand what is being highlighted would also be helpful.

Generic colours not to be used i.e. green, blue, red and yellow.

Under Section 2 – Page 9 – it would be helpful to specify the point the target period commenced as well as when it is expected to be reached.

SABS – there was discussion about the SABs in the community. Helen Wright indicated that the work with the IV drug using community is at an early stage. The numbers are small and not all are as a result of IV drug use. A breakdown of the different causes will be included for the next meeting. Fife has a larger percentage of IV drug users than other Boards and this requires thoughtful handling to keep them engaged with this initiative.

HWr

Medicines Safety Work - Dr Elliot advised the workstream leads are now meeting regularly to discuss the medicines reconciliation work.


007/17 CLINICAL STRATEGY

Dr Elliot advised mapping work was almost complete and the Strategy was moving forward to the next phase of implementation. Work will continue over the next three to six months for all strands. Jann Gardner has met with H&SCP colleagues and will ensure all strands interlink in to the Joint Strategic Commissioning Plan of the IJB.

Paul Hawkins highlighted the Strategy needs to move forward faster and Jann Gardner and Michael Kellet will progress this with a view of having a Regional conversation on the shape of Acute services for the future.

Dr Bisset said it would be helpful to see a paper at the next NHSFCGC clarifying the strategy implementation.

FME

Moira Adams sought clarity on the Workforce Strategy. Paul Hawkins said there is a National Strategy out for consultation. Alison Rooney advised at the IJB Locality Planning meeting it had been highlighted that certain services would be aligned to other boards as the regional planning discussions develop. The IJB Strategic Plan has another two years to be delivered. This will be integrated into the clinical strategy implementation.

008/17 GOVERNANCE ITEMS

a) NHS Fife Prevention & Control of Infection Implementation Framework Updatec/f from December 2016

Helen Wright advised this report was for the Committee to note and approve.

Following appointment of a new Infection Control Manager the governance structure had been reviewed and this report takes account of the changes resulting from the review. Helen Wright confirmed this report has been considered by the Infection Control Team.

The Committee welcomed and approved this report.


008/17b) Clinical & Care Governance Strategy

c/f from December 2016

The Committee noted this report will be considered by the IJB in March 2017 and will come back to the NHSFCGC before going to the Board in April 2017 for ratification.

FME

c) Management of Adverse Events Improvement Plan c/f from December 2016

The Committee noted the report which provided an update on the local management of adverse events.

Helen Woodburn highlighted the progress against the key six priorities.

Simon Little asked if there was a timetable for resolution of adverse events. Helen Woodburn advised that incidents are reviewed jointly if they involve both acute and community services. A single system is some way off as integration of the current two incident systems will be required.

Simon Little asked if there was any progress with the inclusion of Non Executives on Safety Walkarounds. Helen Woodburn said this would be considered when reviewing who should be included on the walkarounds.

HWo

Paul Hawkins highlighted to the Committee that NHS Fife currently had one of the best hospital “huddles” in Scotland. There would be value in considering the model of non-executive involvement in patient safety.

Paul Hawkins said it would be helpful to collect adverse events data and prepare a separate report including all multiple incidents.

HWo


008/17d) Novel Procedures

c/f from December 2016

Dr Elliot confirmed this item had been discussed at EDG and would be reconsidered at the NHSFCGC in April 2017.

FME

e) Medication Safety Action Planc/f from December 2016

The Committee noted the update and progress across the organisation following the maternity controlled drug incident on 7 November 2016.

The Committee noted following the incident and review across the organisation there has been a 130% increase in medication incident reporting within the Women and Children’s Directorate which points towards a more open culture.

Helen Wright highlighted to the Committee other issues around medication were identified where there could be more rigour around adherence to policies. The aim is still to reduce medication errors as far as possible across the organisation.

Alison Rooney queried Point 4 of Appendix 2. Helen Wright agreed to look at this and report the audit process back to the NHSFCGC in April 2017.

HWr

Simon Little commended the pace and achievement of the exercise and asked if there were any general lessons for the organisation. Paul Hawkins advised this highlighted the systems in place and following the review, pharmacy now act as an advisory function. Cultural change had also taken place following the incident although this was still developing. Helen Wright highlighted that the incident had highlighted the need to remind professionals about their accountability for practice.


008/17Dr Bisset asked that this be reviewed again in April 2017.

HWr

f) ASD Clinical Governance ToR

The Committee noted the Acute Services Division Clinical Governance Committee Terms of Reference.

g) Clinical Governance Risk Report (July – December 2016)

The Committee noted this report which provides information and assurance on the management of the risks contained in the NHS Fife’s high level risk registers categorised under the Strategic & Operational risk type and Clinical Governance risk subtype or otherwise mapped to the NHSFCGC.

Dr Elliot advised she will discuss information risks with Jann Gardner, as SIRO, feeding information into the Board Assurance Framework and report back to the NHSFCGC.

FME

Simon Little highlighted assurance from H&SC does not seem to have been confirmed.

It was agreed to review the assurance process for the IJB Care & Clinical Governance Committee to the IJB and NHS Fife Clinical Governance Committee.

FME

h) Child Protection Reporti) Corporate Risk 520 (Child Protection)

Inspection Report

It was agreed both these items be taken together.

Helen Wright advised Risk 520 – Child Protection remains on the register due to a previous significant case review.


008/17Helen Wright advised the Child Protection report provides the Committee with an update to the previous report submitted to the Committee in February 2016.

Helen Wright advised since the last report a lot of progress has been made especially in relation to multi agency work for Immediate case reviews. Another area of progress was training as highlighted in Section 4 of the report.

Alison Rooney asked, under Section 2.2, if there was any risk to the organisation with the Lead Paediatrician for Child Protection fully retired at the end of July 2016 and the vacancy not being successfully recruited to. Helen Wright advised work was ongoing with other Boards to identify a consultant (from Borders) who could assist if any risks were identified.

j) NHS Fife Incident Report1 July 2016 – 31 December 2016

The Committee noted the paper which provides an overview of incidents reported in NHS Fife from 1 July 2016 – 31 December 2016.

Alison Rooney queried the Bar chart on Page 3 of the report and queried the Number of incidents against Corporate Directorates. Dr Elliot agreed to check what this covers. Also what is covered under NHS Fife Board. It was agreed this needs to separate out incidents relating to the IJB. It was also agreed for the future that the report should just cover Board and ASD incidents.

FME

Alison Rooney queried the Table 2 on Page 4 and sought clarity on the reason for the increase in tissue viability reporting. Gillian Fenton advised that one of the reasons for the increase was due to infra structure changes. Agency staff are now recording incidents on DATIX which in the past had not previously been recorded.

008/17


Dr Elliot also advised pressure ulcers are classed as major / extreme. Alison Rooney asked if this correlated back to the quality report. Dr Elliot agreed to clarify.

FME

Scott McLean advised the Committee it was important to understand what goes on within the Acute Division / organisation to help inform this report. At the daily huddle extreme DATIX issues such as cardiac arrests and pressure ulcers are discussed. These are then aggregated over three directorates who have their own governance arrangements. In the regular Performance reviews incidents in both directorat4es are now reviewed to check for hot spots. This goes to clinical governance and aggregates up to this report.

Dr Elliot advised not all incidents in the service refer to beds. It was agreed Dr Elliot and Gillian Fenton would look at community parameters and bring a report back to the NHSFCGC.

FME/GF

Paul Hawkins highlighted community issues should also go through the IJB governance route.

009/17 ANNUAL REPORTS

a) Radiation Protection Annual Reportc/f from October & December 2016

Dr Elliot advised this Committee had recently been reconstituted and she had taken on the role of Chair. A report would be available in due course.

b) Clinical and Staff Governance for General Practicec/f from October 2016

The Committee noted the update report for 2015/16 which gives assurance that contractual, legal and professional governance requirements are being achieved and suitably monitored.

009/17 Simon Little highlighted that within Para 4.2 it makes reference to CHPs. Dr Elliot agreed to amend.

FME


c) NHS Fife Prevention & Control of Infection Annual Report 2015/2016c/f from August, October & December 2016

The Committee considered and approved the content of the Annual Report for 2015/2016. This report provides information to the ICC, CGC and Board on progress against the Infection Prevention & Control programme of work and compliance with national guidance and targets.

Helen Wright highlighted to the Committee the Executive Summary on Page 5 of the report lists the work undertaken.

d) SCAN Annual Report 2015/2016c/f from August, October & December 2016

Dr Elliot advised the Committee this report was not available as it has not yet been produced. The Committee noted the report would follow in due course.

010/17 EXECUTIVE LEAD REPORTS AND MINUTES FROM LINKED COMMITTEES

Dr Bisset advised all items under this section would be taken without discussion unless any particular issues were raised.

a) ASD CGC 18 January 2017c/f to 12 April 2017


b) Quality Safety & Governance 21 December 2016 – Unconfirmed

Dr Bisset questioned why the NHSFCGC were being asked to approve the ToR for the Adverse Events Group as set out in the Template? Dr Elliot responded that this group overseas reporting across the ASD and IJB.

Simon Little advised the reporting template accompanying the minutes was very helpful and asked what the process was for escalation of items. Dr Bisset said the template was to make NHSFCGC aware of any issues and ask pertinent questions.

c) Infection Control Committee7 December 2016

d) Fife Research Governance Group18 January 2017

e) Area Radiation Protection17 November 2016

Alison Rooney queried why there was only one meeting per year. Dr Elliot advised she had only recently taken on the role of Chair of this Committee and confirmed there were usually only two meetings per year.

f) Fife Area Drugs & Therapeutics Committee 7 December 2016 - Unconfirmed

g) IJB24 November 2016

h) Patient Focus Public Involvement 30 November 2016 – Unconfirmed

Simon Little raised the risk highlighted under Section 3. Helen Wright advised the PFPI Committee was meeting on 16 February 2016 where the wider engagement and revised membership would be discussed.


i) Health & Safety Governance 8 December 2016 - Cancelled

j) NHS Fife Hospital Transfusion Committee28 January 2016, 28 April 2016, 28 July 2016, 27 October 2016

It was noted one of the responsibilities for the NHS Fife Transfusion Committee is that the minutes would be sent to the Clinical Governance Committee. The transfusion committee meets quarterly. It had been agreed that the minutes should come to the NHSFCGC as this covers the whole system.

011/17 ITEMS FOR NOTING

a) NHS Fife Activity Tracker

Noted with no comments.

b) NHS Fife Clinical Governance Committee Workplan 2016/17

Noted with no comments.

c) SLWG : Radiology Services in South East Scotland

Dr Bisset highlighted to the Committee that the work achieved by Scott McLean and his team over the short period of time was remarkable and should be commended.

012/17 AOCB

a) Care & Clinical Governance Minutes

It was agreed that the Chair would discuss with the Chair of the IJB and DR Elliot the reporting arrangements for the minutes of the IJB Clinical and Care Governance Committee.

LB

013/17 DATE OF FUTURE MEETINGWednesday 12 April 2017 at 2pm in Meeting Room 2 within Ward 6 at Victoria Hospital


confirmed - fifeadmin.fifedirect.org.uk/weborgs/nhs/uploadfiles/...150217… · web...

Documents