NHS GRAMPIAN
CLINICAL GOVERNANCE COMMITTEE REPORT
Board Meeting
02 04 13
Open Session
Item 9.1
Introduction
The following key agenda items were discussed at the NHSG Clinical Governance
Committee meeting on Friday 30th November 2012 and it was agreed that they should be
reported to the NHS Grampian Board.
Strategic context
The Clinical Governance Committee acknowledged it had a role in seeking assurance for
the clinical risks extracted from the Strategic Risk Register, as per its remit below:
Clinical Governance Committee. This Committee has the responsibility, on behalf of the
NHS Grampian Board, for reviewing and challenging risks that are on the strategic or
corporate risk registers in respect of clinical governance issues. It should be satisfied that
all clinical risks have been appropriately identified and that the control measures that are
in place and that are planned to be in place are adequate to manage the risk identified.
The relevant clinical risks include:
 853 Patient safety culture is compromised and is not evidenced in practice.
 586 Future services are not developed in partnership with Local Authorities,
third sector, independent contractors and the community.
Discussion
1. External Review of the Management of Adverse Events in NHS Grampian by
Healthcare Improvement Scotland
This relates to strategic risk 853 Patient Safety culture is compromised and is not
evidenced in practice
The Committee noted the informal positive feedback presented to the Chief Executive and
awaits further detail and recommendations expected within the full report.
2. The Implementation and Embedding of the Unscheduled Care Pathways
This relates to strategic risk 853 Patient Safety culture is compromised and is not
evidenced in practice
The Committee was briefed on the opening of the Emergency Care Centre on the
Foresterhill site on 10th December 2012 and the introduction and implementation of
unscheduled care pathways which are designed to facilitate the journey of a patient to the
most appropriate environment with early access to specialist care. The key risks identified
included ensuring staff engagement in the process, length of stay and the 4 hour A&E
targets. The Committee agreed there were a number of issues to be addressed and asked
for further assurance around data analysis and patient satisfaction to be made available at
the next Clinical Governance Committee meeting.
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3. Recruitment of Nursing Staff
This relates to strategic risk 853 Patient Safety culture is compromised and is not
evidenced in practice
The Committee was concerned to hear of a thematic issue around availability and
recruitment of appropriate numbers of nursing staff. This is described as a high risk
throughout many of the Sector reports including Mental Health, Emergency Care Centre,
Prison service, Paediatrics and Community Nursing. It was agreed by the Committee to
raise this with the Board and ask the Director of Nursing & Quality to discuss with the
Chief Operating Officer and the Delivery Team and provide further details of risk mitigation
at a future Clinical Governance Committee meeting.
Recommendations
The Board is asked to note this report from the Clinical Governance Committee and
acknowledge that the Committee’s roles and responsibilities are being met.
Charles Muir
Clinical Governance Committee Chairman
March 2013
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