SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting
Held on Thursday 8 April 2010 at 12.30 pm
In the Brooke Suite, Warwick Hospital
Present:
Veronica Cotterill
Tony Boorman
Michael Cox
(VC)
(TB)
(MC)
David Derbyshire
Alan Harrison
Jane Ives
Steve Mather
Pat Morris
Shirley Rigby
(DD)
(AH)
(JI)
(SM)
(PM)
(SR)
Sue Shelton
John Strachan
Helen Walton
(SAS)
(JS)
(HW)
In attendance:
Marian
Benjamin
Glen Burley
Christine
Georgeu
Annette Gough
Graham Murrell
Emma Ratley
Sheila Newbold
(MB)
Non Executive Director and Chair
Non Executive Director
Acting General Manager (GM) for the Surgical Division and
deputising for the Chair of the Surgical Audit and Operational
Governance Group (SAOGG)
Non Executive Director
Non Executive Director
Director of Operations and Nursing
Medical Director
Head of Governance
Acting Chair of the Medical Audit and Operational Governance
Group (MAOGG) (present from Minute 10.069 to 10.085)
Patient Safety Manager/ Emergency Planning Lead
Associate Medical Director (AMD) for Clinical Governance
Associate Director of Nursing (Present from Minute 10.070 to
10.085)
(GB)
(CG)
Clinical Audit and Effectiveness Specialist (present for Minute 10.072
and 10.073)
Chief Executive (Present until Minute 10.085)
Matron for Infection Prevention and Control (Present for Minute 10.069)
(AG)
(GM)
(ER)
(SM)
Clinical Governance Midwife (Present for Minute 10.070)
Chairman
Compliance Manager
Committee Administrator
Non Executive Director and Chair (VC) welcomed Mr John Strachan, the newly appointed
Associate Medical Director for Clinical Governance, to the Meeting.
MINUTE
10.065
ACTION
APOLOGIES FOR ABSENCE
No Apologies were received.
10.066
DECLARATIONS OF INTEREST
No interests were declared.
10.067
MINUTES OF THE PREVIOUS MEETING HELD ON 11 MARCH 2010
The minutes of the meeting held on 11 March 2010 were agreed as an
accurate record of the meeting and were signed by the Chair.
Resolved – that, the minutes of the meeting held on 11 March 2010
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
MINUTE
ACTION
were agreed as an accurate record of the meeting and were signed by
the Chair.
10.068
MATTERS ARISING AND PROGRESS MONITORING REPORT
10.068.01
Clinical Practices Group Annual Report and approval of the Terms of
Reference (Minute 09.066)
The item was discussed under the main agenda item (Minute 10.075)
Resolved that the position be noted and closed
10.068.02
Blood Transfusion 6 monthly Report (Minute 09.099)
The Director of Operations and Nursing confirmed that the appropriate
process for the risk assessment and approval of new surgical procedures JI/SM
had not yet been submitted to Management Board.
Resolved – that, the appropriate process for the risk assessment and JI/SM
approval of surgical procedures be instigated via Management Board.
10.068.03
Clinical Audit and Effectiveness Department Quarterly Report (Minute
09.216)
The Priority List of Audits was discussed under the main agenda item
(Minute 10.073 refers).
Resolved – that the position be noted and closed.
10.068.04
SAOGG 6 monthly Report and approval of the Terms of Reference (Minute
10.007)
The Acting GM for the Surgical Division confirmed that the Clinical Audit
lead had not yet been appointed for the SAOGG, however the post had MC
been advertised. The Committee would be updated at the July Meeting.
Resolved – that the Committee would be updated at the July
Committee Meeting in respect of the appointment of the Clinical Audit MC
lead for the SAOGG.
10.068.05
Annual Radiation Report (Minute 10.026)
The Terms of Reference for the Coventry and Warwickshire Radiation
Protection Committee would be submitted to the June Committee Meeting
Karen
for approval.
Wentworth
Resolved – that the Terms of Reference for the Coventry and
Warwickshire Radiation Committee would be submitted to the June
Karen
Committee Meeting
Wentworth
10.068.06
MAOGG 6 Monthly Report and Approval of the Terms of Reference (Minute
10.0052)
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
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ACTION
The issues surrounding the continence audit were addressed under the
main agenda item (Minutes 10.072 and 10.073 refers).
Resolved – that the position be noted and closed.
10.068.07
MAOGG 6 Monthly Report and Approval of the Terms of Reference (Minute
10.052)
The Head of Governance explained that she had raised the issue of the
underlying reasons for complaints relating to the Medical Division at the
latest MAOGG meeting and it had been agreed that this would be addressed
at every third meeting of the Group. This feedback would therefore be
included in the next 6 monthly Report submitted to the Committee from the
MAOGG.
Resolved – that the position be noted and closed.
10.068.08
Update re: Healthcare Commission Report Action Plan (Minute 10.056)
The Report and Action Plan relating to the Review of Safeguarding Children
was discussed under the main agenda item (Minute 10.078 refers).
Resolved – that the position be noted and closed.
10.068.09
Review of the Schedule of Business for the Clinical Governance Committee
(Minute 10.058)
The Report on the CQUIN Scheme was discussed under the main agenda
item (Minute 10.076 refers).
10.069
MRSA AND CLOSTRIDIUM DIFFICILE (C DIFF) INFECTION DATA
UPDATE
The Matron for Infection Prevention and Control presented the Update to the
Committee for information. She confirmed that there were no cases of
MRSA Bacteraemia during March, therefore the total to date continued at 5
compared against the annual target of 12 and the target for next year had
been set at 3. The total number of MRSA non bacteraemia for March was 7
(hospital acquired). Two cases had recently be notified, both of which
occurred on Guy Ward and the Ward was currently closed due to suspected
norovirus. There had been 3 cases of hospital acquired C Diff during March
with a total to date of 54 against a target of 108 and the target set for next
year would be 51. The Chief Executive congratulated the staff involved on
this much improved result. It was note that ITU had a particularly good
outturn with only 1 case of MRSA and 1 case of C.difficile for the year. The
Matron for Infection Prevention and Control emphasised the importance of
root cause analysis but this was not yet embedded in all areas.
Resolved – that, the position be noted.
10.070
MATERNITY GOVERNANCE REPORT – Q3
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
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ACTION
The Clinical Governance Midwife presented the Maternity Governance
Report for Quarter 3. She highlighted the rise in the number of still births
which were currently running at 6 for quarter 3. A Review had taken place to
analyse these cases and the majority of the babies involved were less than
26 weeks old and no internal issues were found. There had been further
cases in quarter 4 and these would be audited to ascertain any
commonality. It was noted that the Report should have read that the still
birth rate for 2010 (not 2009) was 3.9 per 1000. The Chairman asked
whether there were any causal factors involved, for example antenatal care
or population demography. The Associate Director of Nursing explained that
some of the still births were likely to be late terminations as there were often
delays in making this decision and she was confident that the Maternity
Department had a robust process in place. The Committee was concerned
about the still birth rate and it was agreed that the Medical Director and the
Associate Director of Nursing would review the cases and submit a report to SM/HW
the July Committee Meeting.
Non Executive Director (TB) highlighted the ‘red flag’ for long length of stay
for normal births (see Enclosure relating to Minute 10.072). The Director of
Operations and Nursing explained that she had met recently with the
midwives to discuss the length of stay and she had written to the Head of
Midwifery as a result of this as she believed there were procedural
improvements which could be made. The Clinical Governance Midwife
displayed the ‘talkback’ cards which were routinely distributed to mothers on
the Unit to promote constructive feedback. It was noted that the table in the
section Adverse events that affect staffing levels should have read -8.04
total for December and -7.47 total staff for December.
Non Executive Director (AH) asked about the SUI where a doctor had failed
to renew their professional registration and it was explained that this was
highlighted in a routine check. Non Executive Director (AH) highlighted the
incident relating to the delayed removal of clinical waste but the Chief
Executive explained that this was a one-off incident which had been
rectified.
Concern was also expressed over the absence rate of 8.3% and it was
reported that this was in part due to some long-term sickness issues which
were not work stress related.
Resolved – that, the Medical Director and the Associate Director of
Nursing present an analysis of the still birth cases to the next
Committee Meeting.
10.071
MORTALITY REPORT
The Head of Governance presented the Mortality Report to the Committee
for information. She noted the reduction in the March 2010 mortality rate.
The Trust would start to use the CHKS tool instead of Doctor Foster and
training for this tool would take place on 19 April 2010. The Chief Executive
confirmed that the Mortality Group had reviewed mortality for February with
no significant findings however he commented that the process now in place
for identifying mortality was much more robust particularly in Orthopaedics
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SM/HW
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
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ACTION
where input from the new consultant, Dr Andrew Shepherd was having a
positive effect. Each specialty was now reviewing deaths in their area in
order to identify trends or risk factors. The Committee noted that the high
mortality rates in February coincided with a period of high bed occupancy
where the percentage of older patients being admitted increased. The
Chairman asked whether there were any specific indicators found during the
period of high mortality and Non Executive Director (TB) was concerned
whether during these very busy periods patients were not receiving correct
care. The Medical Director explained that he had examined the data for
September 2010 (the lowest month for mortality) and compared this to
February 2010 (the highest month), mapping the time spent in A&E against
mortality rate and found that they were almost identical for the two months.
He concluded that the high mortality rate was due to a complex variety of
reasons and not just long waits in A&E. Non Executive Director (DD) was
concerned that patients that were outliers were not receiving appropriate
care. Non Executive Director (AH) noted that there was a year on year
reduction in the crude mortality rate and asked whether it was understood
why this was occurring. It was confirmed that this was being examined by
the Mortality Group
Resolved – that the position be noted.
10.072
CLINCIAL AUDIT AND EFFECTIVENESS QUARTERLY REPORT
The Clinical Audit and Effectiveness Specialist presented the Report to the
Committee for information. The Non Executive Directors were concerned
that there was insufficient narrative in the Report to provide a reasonable
level of assurance and Non Executive Director (TB) highlighted the Red Flag
for Tonsillectomy in this respect. Non Executive Director (DD) highlighted
the Extraction of Cataracts explaining that again there was insufficient
explanation to enable members to understand whether or not there was
significant concern. Although these red and green flags were discussed in
detail at the MAOGG and SAOGG the Committee stressed the need for
sufficient information to be reported to provide a reasonable level of
assurance. Non Executive Director (AH) was concerned at the lack of detail
about dates for completion and follow up action within the Report. The
Chairman suggested that a presentation from CHKS to the Committee would
be valuable and the Head of Governance would arrange this.
PM
Resolved – that the Head of Governance would arrange for a
presentation to the Committee by CHKS by June 2010.
PM
10.073
ANNUAL AUDIT PROGRAMME
The Clinical Audit and Effectiveness Specialist presented the Annual Audit
Programme for 2010/11 to the Committee for approval. She outlined the
current audits being carried out and those proposed for 2010/11 together
with a categorisation of the audits in respect to where these had originated.
The Chairman expressed concern that the audit programme did not appear
to be aligned to the Trust’s priorities and he proposed a Trust audit strategy,
linking audit to the Trust’s overall priorities and also suggested an overview
analysis. The Medical Director suggested that the Clinical Audit Committee
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
MINUTE
ACTION
should be reconvened and should meet on a regular basis to determine a SM
programme of audits and he would ensure that this committee would be set
up. It was agreed to accept the Audit Programme as an interim working
paper and a Clinical Audit Strategy and a revised Audit Plan for 2010/11
would be discussed at the Clinical Audit Committee and the results of the SM
discussions would be reported back to the Clinical Governance Committee.
Non Executive Director (AH) was concerned at the lack of detail about dates
for completion and follow up action within the Programme.
Resolved – that,
(A)
(B)
10.074
the Medical Director would reconvene the Clinical Audit
Committee which would meet on a regular basis and
the Clinical Audit Committee would report back to the
Committee with the results of discussions about the Clinical
Audit Strategy and the revised Audit Plan for 2010/11.
SM
SM
REVALIDATION OF DOCTORS - UPDATE
The Medical Director gave a verbal update to the Committee with regard to
the latest position on Revalidation for Doctors. He explained that the
General Medical Council (GMC) would be changing the way doctors within
the UK were regulated to practise medicine. They would be required to hold
a licence and a new system called Revalidation would begin that would
require doctors to renew their licence to practise every 5 years. The
purpose of this new approach was to give patients a regular assurance that
licensed doctors were up to date and fit to practise. However the Medical
Director explained that there was very little guidance so far on the process.
He was arranging an Awayday on 23 April 2010 to discuss the implications
of Revalidation with the AMDs and he would report back to the Committee SM
on the outcome of this Awayday.
Resolved – that, the outcome from the Revalidation Awayday would be
reported back to the Committee.
SM
10.075
CLINICAL PRACTICES GROUP ANNUAL REPORT AND APPROVAL OF
THE TERMS OF REFERENCE
The Head of Governance presented the Report to the Committee for
information. It was noted that a large number of maternity policies were
reviewed and updated in the period, linking into the CNST accreditation for
maternity.
Terms of Reference
The Terms of Reference for the Clinical Practices Group were presented to
the Committee for approval. It was noted that the Policy Formulation Group’
should have read ‘Policy Review Group’, in the ‘Responsibilities’ section.
The Terms of Reference were approved subject to the above amendment.
Resolved – that, the Terms of Reference for the Clinical Practices
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
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ACTION
Group be approved subject to the amendment of the words ‘the Policy
Formulation Group’ to read ‘Policy Review Group’, in the
‘Responsibilities’ section of the Terms of Reference.
10.076
CQUIN SCHEME
The Director of Operations and Nursing presented the leadership,
accountability and reporting schedule for the Commissioning for Quality and
Innovation (CQUIN) scheme. The document outlined the areas agreed with
NHS Warwickshire along with the financial value of these. Further
explanation of the targets and actions to be undertaken to achieve these
would be provided at the next Meeting. Any performance issues relating to JI
these schemes would be managed by the Finance and Performance
Committee.
Resolved – that a more detailed report would be submitted to the next
Committee Meeting regarding the CQUIN Scheme.
JI
10.077
APPROVAL OF THE TERMS OF REFERENCE FOR THE INFECTION
PREVENTION BOARD
The Chief Executive presented the Terms of Reference for the Infection
Prevention Board to the Committee for approval. It was noted that the
Board now had a broader remit to cover all hospital acquired infections and
would be reporting to the Clinical Governance Committee on a 6 monthy
basis unless there were specific issues of concern in which case it would
report more frequently and would also report to the Board of Directors. It
was therefore agreed that item 2.9 should be amended to read’ Provide
assurance to the Clinical Governance Committee through 6 monthly reports
of progress against the annual programme of work and performance
targets’. The ‘Head of Governance’ should be added to the ‘Membership’
section of the Terms of Reference. Item 2.12 should be amended to read
‘Provide assurance to the Clinical Governance Committee through 6 monthly
reports on compliance with the Health Act’s Code of Practice and associated
action plans’.
The Terms of Reference were approved subject to the above amendments.
Resolved – that, the Terms of Reference be approved subject to the
following amendments:
(a)
(b)
(c)
item 2.9 to be amended to read ’Provide assurance to the
Clinical Governance Committee through 6 monthly reports of
progress against the annual programme of work and
performance targets’ and
the Head of Governance to be added to the Membership
section and
Item 2.12 should be amended to read ‘Provide assurance to
the Clinical Governance Committee through 6 monthly
reports on compliance with the Health Act’s Code of Practice
and associated action plans’.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 8 April 2010
MINUTE
10.078
ACTION
ACTION PLAN FOLLOWING THE SAFEGUARDING CHILDREN REVIEW
The Associate Director of Nursing presented the Action Plan following the
Safeguarding Children Themed Review for information. It was reported that
the concerns about the availability and continuity of the ‘named Doctor’ (due
to the part-time employment of the individual) raised by the review had been
addressed. Reciprocal arrangements had been made with the George Elliot
Hospital to ensure that there was always a suitable ‘named Doctor’ available
to respond to safeguarding issues. In addition it was reported that a new
full-time safeguarding lead had been appointed in the Trust.
Resolved – that, the position be noted.
10.079
ANY OTHER BUSINESS
There was no further business under this item.
Resolved – that, the position be noted.
10.080
CONFIDENTIAL MINUTES FROM THE MEETING HELD ON 11
FEBRUARY 2010
10.081
CONFIDENTIAL MINUTES FROM THE MEETING HELD ON 11 MARCH
2010
10.082
CONFIDENTIAL MATTERS ARISING AND PROGRESS MONITORING
10.083
UPDATE ON SERIOUS UNTOWARD INCIDENTS (SUI) (CONFIDENTIAL
10.084
REPORT RE: SUI 2009/8651
10.085
CONFIDENTIAL AOB
10.086
DATE AND TIME OF NEXT MEETING
The next meeting will be held on Thursday 13 May 2010 at 12.30 pm in the
Brooke Suite, Warwick Hospital.
Signed
______________________________ (Chair)
Chair of the Clinical Governance Committee
Page 8 of 8
Date ___________________