NHS GRAMPIAN
CLINICAL GOVERNANCE COMMITTEE REPORT
Board Meeting
21 02 12
Open Session
Item 7.5
Introduction
The following key agenda items were discussed at the NHSG Clinical Governance
Committee meeting on Friday 25th November 2011 and it was agreed they should be
reported to Grampian NHS 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 plan as per 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. They 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 not adequate and is not evidenced in practice.

586 Community and independent contractors (Support from independent
contractors is required to take forward strategic objectives e.g. shifting the
balance of care.)
Discussion
1. Scottish Patient Safety Programme
This relates to strategic risk 853 Patient Safety
The Clinical Governance Committee heard a report from the Scottish Patient Safety
Programme Manager that NHS Grampian has demonstrated sustained improvement in
both process and outcome measures within each of the programme work streams. NHS
Grampian is now one of the top three Boards in Scotland. The Committee was interested
to hear about various areas where there was evidence of continuing improvement and
spread of the learning. The Programme Manager informed the Committee that during a
site visit to Grampian in June 2011 it was noted that Grampian had the best medication
improvement work in the country. Grampian ran a successful Medication Safety Week
during 31st October to 4th November. The Committee was pleased to note that NHS
Grampian is now being recognised nationally for being a leading organisation in this
particular field.
Health Care Associated Infection Report
This relates to strategic risk 853 Patient Safety
The Clinical Governance Committee again received a Healthcare Associated Infection
update report and was assured that infection rates and interventions are monitored and
1
appropriate action was being taken to reduce the number of healthcare associated
infections in NHS Grampian. The Committee was pleased to note that the latest available
figures for hand hygiene were at 98% across Grampian and that cleaning compliance
remains consistently higher than the national average. The downward trend for Clostridium
difficile infection over the last 12 months was being maintained. It was noted by the
Committee that although the total Staphylococcus aureus bacteraemia figures do fluctuate
a downward trend had also been maintained over the previous 12 months. The Clinical
Governance Committee will continue to be kept fully informed about the ongoing
improvement work
3. Dementia and Elderly Care Update
This relates to strategic risk 853 Patient Safety
The Clinical Governance Committee was informed that NHS Grampian will be required to
respond to both work streams from Healthcare Improvement Scotland around Older
People in Acute Care and the Dementia standards. Work was already being undertaken
on the completion of the self assessment for the Older People in Acute Care standards
which was submitted at the beginning of December. The Committee noted that NHS
Grampian is likely to be inspected early in 2012. Analysis work has been undertaken to
prepare for inspection including a rapid review of care for older people in hospital including
some specific areas within the dementia standards. SBAR reports were provided from all
areas and the findings shared along with areas of good practice and a number of identified
gaps. These included the requirement for a consistent approach across all disciplines in
the care of older people. The Committee was aware that this was high on the Board’s
agenda and noted that significant work had already been undertaken by staff across NHS
Grampian to ensure that improvement trends could be evidenced.
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. The
Committee asks the Board to recognise the significant work of small teams of NHS
Grampian staff achieving good outcomes for the benefit of patients.
Charles Muir
Clinical Governance Committee Chairman
November 2011
2