Highland NHS Board
2 December 2008
Item 7.3
CLINICAL GOVERNANCE COMMITTEE
Report by Dr Lesley Anne Smith, Head of Clinical Governance & Risk Management
The Board is asked to:



Note that the Clinical Governance Committee met on 28 October 2008 with
attendance as noted below.
Note the Assurance Report and agreed actions resulting from the consideration of
the specific items detailed below.
Note the items for discussion at the next meeting to be held on 10 February 2009.
Committee Members
Present:
Dr Vivian Shelley, Chair
Mr Ian Gibson
Cllr Margaret Davidson
Mr Ray Stewart
Also Present:
Dr Ian Bashford, Medical Director
Mrs Anne Clark, Non-Executive Director
Ms Heidi May, Nurse Director
Dr Lesley Anne Smith, Head of Clinical Governance and Risk
Management
Dr Susan Vaughan, Epidemiologist
In Attendance:
Ms Pauline Craw, Assistant General Manager, North Highland
CHP
Dr Moray Fraser, Clinical Lead, North Highland CHP
Mr Nigel Hobson, Associate Nurse Director
Ms Aileen Fraser, Area Information Security Manager
Mr Bill Reid, Interim Head of eHealth/Head of eHealth
Implementation
Mr Douglas Seago, Head of Facilities
Mrs Mirian Morrison, Clinical Governance Development Manager
Miss Irene Robertson, Board Committee Administrator
Apologies - Dr Eric Baijal, Mr Garry Coutts, Mr Quentin Cox and Dr Roger Gibbins
1.
ITEMS FOR DISCUSSION
The items discussed at the meeting are noted below:
i. Emerging Issues
ii. Update on items previously discussed at Clinical Governance Committee
iii. Clinical Governance and Risk Management within Operational Units – North
Highland CHP
iv. Clinical Governance & Risk Management Performance Report
v. Information Governance Update
vi. Information Security at Closed Sites
vii. Data Security and Handling – eHealth and Internal Audit Response
viii. Internal Audit Progress Report
ix. Forthcoming NHS Quality Improvement Scotland (NHS QIS) Review Visits
x. NHS QIS Clinical Governance & Risk Management Standards
xi. Clinical Risk Management
xii. Better Together – Patient Experience Programme
Working with you to make Highland the healthy place to be
2.
ITEMS FOR DISCUSSION AT NEXT MEETING ON 10 FEBRUARY 2009
 Emerging Issues
 Clinical Governance and Risk Management within Operational Units – A CHP (to
be identified)
 Clinical Governance & Risk Management Performance Report (to include detailed
analysis of Medication Incidents)
 Report from Violence & Aggression Steering Group
 Report on Slips, Trips and Falls
 Review of Effectiveness of new Area Drug & Therapeutic Committee structure
 Review of Operational Clinical Governance & Risk Management arrangements
 Independent Advice and Support Service Update
 NHS QIS Clinical Governance & Risk Management Standards
 Internal Audit Reports
 Scottish Patient Safety Programme
 Scottish Public Services Ombudsman Reports
 LSAMO Work Programme and NMC Report
3.
CONTRIBUTION TO CORPORATE OBJECTIVES
This performance report demonstrates how NHS Highland is achieving its corporate
objective of ensuring that services delivered are of high quality and clinically effective.
4.
GOVERNANCE IMPLICATIONS
This performance report has a direct impact on clinical governance and demonstrates
performance against responding to complaints, clinical effectiveness activity, patient
safety and NHS Quality Improvement Scotland reviews.
5.
IMPACT ASSESSMENT
This report does not require impact assessment.
Dr Lesley Anne Smith
Head of Clinical Governance & Risk Management
18 November 2008
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CLINCIAL GOVERNANCE COMMITTEE – ASSURANCE REPORT
ISSUE: EMERGING ISSUES
The Committee received an update on significant incidents which had emerged since the last committee meeting.
Issues/Risks
Assurance
Actions
The Clinical Governance Committee require
Serious incidents are investigated according to
Action Plans relating to the recent incidents to
assurance that incidents are appropriately
the NHS Highland Policy and procedures.
be submitted to the appropriate operational
investigated and that steps are being taken to
Appropriate Escalation Procedures are in place. management clinical governance and risk
learn lessons and ensure the risks of future
management groups for monitoring.
occurrence are minimised.
Action Plans are developed for both local and
national incidents and structures are in place to Final Reports on the recent incidents to be
ensure that progress against these is monitored submitted to the Clinical Governance
as required.
Committee once available.
Actions: I Bashford/ H May/ L A Smith
ISSUE: UPDATE ON ITEMS PREVIOUSLY DISCUSSED AT CLINICAL GOVERNANCE COMMITTEE
The Committee received a report on items which had previously been considered by the Clinical Governance Committee and where actions had not
progressed as agreed.
Issues/Risks
Assurance
Actions
To ensure that items previously raised at the
A rolling action plan has been prepared which
Items to be followed up at future meetings as
Clinical Governance Committee are followed up will be monitored at each Committee meeting.
agreed in the Plan.
as agreed.
Action: L A Smith/ I Bashford/A Clark
Working with you to make Highland the healthy place to be
ISSUE: CLINICAL GOVERNANCE AND RISK MANAGEMENT WITHIN OPERATIONAL UNITS – NORTH HIGHLAND CHP
The Locality General Manager and Clinical Director for North Highland CHP gave a presentation to the Committee on the current clinical governance
& risk management issues within the CHP and how these are being addressed.
Issues/Risks
Assurance
Actions
To ensure that clinical governance and risk
North Highland CHP confirmed that the CG&RM North Highland CHP CG&RM Group to consider
management arrangement within North
Group was well established with appropriate
how to best support staff to ensure that clinical
Highland CHP are appropriate and to identify
membership and meeting on a regular basis.
governance is embedded in everyone’s clinical
any issues which are compromising the ability to
practice across the area.
deliver this.
North Highland CHP CG&RM Group to ensure
capacity issues in relation to Scottish Patient
Safety Programme (SPSP) are addressed
and/or escalated as necessary.
Actions: P Craw/ M Fraser
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ISSUE: CLINICAL GOVERNANCE & RISK MANAGEMENT PERFORMANCE REPORT
The Committee received a report detailing performance as at the end of July 2008 against complaints targets, performance in relation to patient
safety and embedding clinical governance and risk management across operational units.
Issues/Risks
Assurance
Actions
To review performance in relation to clinical
Complaints information is being analysed on a
It was agreed to present three complex cases
governance & risk management issues at a
regular basis to identify trends and lessons
which were difficult to categorise at the next
Board and an Operational Unit level.
learnt for sharing across the organisation. The
meeting to give the Committee a better
majority of complaints relate to clinical treatment understanding of what was involved.
Action: L A Smith
in one form or another. These complaints are
often complex, involving several different
elements and covering a wide range of issues.
Concern was raised by the committee about
whether lessons were being learnt and shared
from these types of complaints.
Incident information is being analysed on a
regular basis to identify trends and lessons
learnt for sharing across the organisation. The
most recent reports have identified slips, trips
and falls, violence and aggression and
medication as being the three main areas of
concern. Work is underway in a number of
different fora to identify solutions to these.
V&A Steering Group to report to next meeting of
Clinical Governance Committee.
Action: Chair V&A Steering Group
Report on Slips, Trips and Falls prepared by the
Professional Head of H&S to be discussed at
the next meeting of the Clinical Governance
Committee
Action: B Summers
Report on Medication Incidents to be presented
to the next meeting of the Clinical Governance
Committee.
Action: L A Smith
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ISSUE: INFORMATION GOVERNANCE UPDATE
The Committee received a report on progress on implementation of an Information Governance Framework and an assessment of performance
against the Information Governance Standards
Issues/Risks
Assurance
Actions
The need for the Information Governance Action An Information Governance Group is in place
The Information Governance Group to provide a
Plan to deliver an improvement in performance
which reports to the e-Health Steering Group
progress report to the Clinical Governance
against the Information Governance Standards
and to the Clinical Governance Committee.
Committee in 6 months time to include evidence
in line with the target (1 point improvement).
for activities completed and timescales for
An Information Governance Improvement Plan
outstanding actions.
is currently being developed which will allow for
Action: B Reid (Interim Head of e-Health)
monitoring of progress against the Information
Governance Standards.
ISSUE: INFORMATION SECURITY AT CLOSED SITES
Following a recent incident elsewhere in Scotland of confidential information being found in a closed site the SGHD had requested that all Boards
carry out an inspection of relevant premises to ensure information security is not being compromised.
Issues/Risks
Assurance
Actions
To ensure that no patient information is located
Estates and eHealth staff carried out an
Formal Protocol to be finalised and considered
in any closed hospital sites within NHS
inspection of all closed hospital sites to ensure
by Clinical Governance Committee when
Highland.
that no patient information was located on those available.
premises. In addition several peripheral sites
Action: B Reid/ D Seago
were visited any and documentation found in
the secured.
A formal protocol to be used in any future site
closures to be developed and implemented.
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ISSUE: DATA SECURITY AND HANDLING
Following events at Her Majesty’s Revenue and Customs (HMRC) involving the loss of data the SGHD had written to all NHS Boards requesting
detailed information on the handling and sharing of data.
Issues/Risks
Assurance
Actions
To ensure that NHS Highland complies with all
Action plan is in place to address any potential
eHealth and Internal Audit to carry out a series
regulations and guidance in relation to secure
risks raised by the HMRC incident within the
of focussed internal audits to provide assurance
handling and sharing of data.
context of NHS Highland controls.
on the compliance of users and departments
with regard to data security and handling within
business critical systems.
Action: B Reid/ Internal Audit
ISSUE: INTERNAL AUDIT REPORTS
The Committee considered the recent Internal Audit Reports on the Review of Raigmore Hospital and the Review of Argyll & Bute Hospital
Issues/Risks
Assurance
Actions
To ensure that any recommendations relating to All Internal Audit Reports have an Executive
Further information to be sought from Raigmore
clinical governance issues identified by the
Sponsor and Management Lead and progress is Management team in terms of follow up actions
reports are followed up and actioned as
monitored at the Audit Committee.
on the clinical governance issues identified in
necessary.
the reports and implementation of any
recommendations.
Action: S Eddie (General Manager, Raigmore
Hospital
ISSUE: FORTHCOMING NHS QIS REVIEW VISITS
The Committee received a report detailing progress with the preparation for the NHS QIS review visits which will take place during 2009.
Issues/Risks
Assurance
Actions
The ability to support three NHS QIS visits
In all cases working groups for each of the
Relevant Action Plans to be submitted to the
during 2009 – Review of Learning Disability
review visits had been or were in the process of Clinical Governance Committee.
Indicators, Food, Fluid and Nutritional Care and being set up.
Action: M Morrison
Out of Hours Emergency Dental Services.
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ISSUE: NHS QUALITY IMPROVEMENT SCOTLAND (NHS QIS) CLINICAL GOVERNANCE & RISK MANAGEMENT STANDARDS
The date for the NHS QIS Review visit for the Clinical Governance & Risk Management Standards has been set for w/c 8 th March 2010.
Issues/Risks
Assurance
Actions
The ability to deliver the HEAT target of an
An Action Plan is in place and is being
The Clinical Governance Committee to act as
improvement of 3 points by March 2010
monitored on a regular basis.
the prime group monitoring progress against the
particularly in relation to the review of the
Standards over the next 18 months.
assessment levels which is currently being
Action: L A Smith
carried out by NHS QIS.
ISSUE: CLINICAL RISK MANAGEMENT
The Committee received a copy of the Clinical (including HAI) Risk Section of NHS Highland’s Corporate Risk Register as at August 2008
Issues/Risks
Assurance
Actions
The need to ensure that the risk register was a
The Register is under continuous review by the
Further reports on Clinical risks to be submitted
dynamic process and in particular that items
Risk Management Steering Group and was
to the Clinical Governance Committee.
which had previously been designated as
updated as necessary. Discussion had taken
Action: L A Smith
‘archived’ were able to be reinstated if
place around the particular risks identified by
necessary.
the committee and appropriate action agreed.
ISSUE: BETTER TOGETHER – PATIENT EXPERIENCE PROGRAMME
The Committee received a report from the Associate Nurse Director of the current position in relation to this national project to measure the patient
experience.
Issues/Risks
Assurance
Actions
The slippage of timescales for implementation
The Associate Director of Nursing is the
The Associate Director of Nursing to provide an
of the programme together with lack of clarity
identified lead for the programme within NHS
update on progress to the next meeting of the
around the exact methodology to be used was
Highland and will be attending a meeting in
Clinical Governance Committee
identified as an area of concern.
November 2008 with the SGHD where further
Action: N Hobson
information will be available.
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