SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting
Held on Thursday 13 May 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
John Strachan
Helen Walton
(DD)
(AH)
(JI)
(SM)
(PM)
(JS)
(HW)
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 (present until Minute 10.101)
Medical Director (present until Minute 10.096)
Head of Governance
Associate Medical Director (AMD) for Clinical Governance
Associate Director of Nursing
In attendance:
Ruth Brown
Wendy Jones
(RB)
(WJ)
Clinical Effectiveness Specialist (present for Minute 10.094)
Assistant General Manager (AGM) for Women’s and Children’s Services
and Head of Midwifery (present from Minute 10.101)
Graham Murrell
Emma Ratley
Maureen Walker
Sheila Newbold
(GM)
(ER)
(MW)
(SM)
Chairman (present until Minute 10.097)
Compliance Manager (Present until Minute 10.104)
AGM for Cancer Services (present for Minute 10.102)
Committee Administrator
The Meeting was inquorate from Minute 10.101.
MINUTE
10.087
ACTION
APOLOGIES FOR ABSENCE
Apologies were received from: Shirley Rigby. Acting Chair of the Medical
Audit and Operational Governance Group; Sue Shelton, Patient Safety
Manager/ Emergency Planning Lead; Diane Shepherd, Moving and
Handling Advisor.
10.088
DECLARATIONS OF INTEREST
No interests were declared.
10.089
MINUTES OF THE PREVIOUS MEETING HELD ON 8 APRIL 2010
The minutes of the meeting held on 8 April 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 8 April 2010 were
agreed as an accurate record of the meeting and were signed by the
Chair.
10.090
MATTERS ARISING AND PROGRESS MONITORING REPORT
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
MINUTE
10.090.01
ACTION
Blood Transfusion 6 monthly Report (Minute 09.099)
The Director of Operations and Nursing confirmed that a policy relating to
the appropriate process for the risk assessment and approval of new
surgical procedures was due to be submitted to Management Board the
following day. The Committee would be updated at the next meeting.
JI
Resolved – that, the Committee would be updated at the next meeting
with regard to the process for the risk assessment and approval of JI
surgical procedures.
10.090.02
Internal Audit – Incident Reporting, Progress against actions (Minute 09.157)
The Head of Governance confirmed that national guidance had been
received regarding Serious Untoward Incidents (SUIs) and following a PM
discussion on categorisation of incidents it was agreed that the new policy
would be presented to the Committee in August 2010.
Resolved – that the new SUI policy would be presented to the PM
Committee in August 2010.
10.090.03
Surgical Audit and Operational Governance Group (SAOGG) 6 monthly
Report and approval of the Terms of Reference (Minute 10.007)
The Acting GM for the Surgical Division confirmed that Mr Robert Jackson
had been appointed as Clinical Audit lead for the SAOGG.
Resolved – that the position be noted and closed.
10.090.04
Revalidation of Doctors – Update (Minute 10.074)
The Medical Director confirmed that the Doctors’ Revalidation Awayday had
taken place on 23 April. There was much work needed to instigate
Revalidation, the aim being to complete by the end of this year but he
thought this timescale was unlikely.
Resolved – that the position be noted and closed.
10.090.05
CQUIN Scheme (Minute 10.076)
A more detailed report was discussed under the main agenda item (Minutes
10.098, 10.099, 10.101, 10.102 and 10.103 refer).
Resolved – that the position be noted and closed.
10.091
MRSA AND CLOSTRIDIUM DIFFICILE (C DIFF) INFECTION DATA
UPDATE
The Medical Director confirmed that there had been no cases of MRSA
bacteraemia reported in the new financial year. There had been 7 cases of
C.difficile reported and this was of concern as the annual target for the Trust
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
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ACTION
was 75 with an internal target set at 40. It was noted that the outbreak of
Norovirus in April and subsequent testing of patients had possibly led to an
increase in the number of C.difficile cases detected.
Resolved – that, the position be noted.
10.092
MORTALITY UPDATE
The Head of Governance tabled the Mortality Update to the Committee and
explained that the April figure saw the continued gradually reducing trend in
crude mortality within the Trust but it was not clear how this compared with
the NHS nationally. The new providers of information, CHKS, would present
at the next Committee meeting and would explain the new formula for
considering comparative mortality (RAMI), which would replace the Dr
Foster’s HSMR formula. The Medical Director cited a recent article from the
BMJ which questioned the validity of correlating deaths in hospitals with
quality.
Resolved – that, the position be noted.
10.093
CARE QUALITY COMMISSION (CQC) OUTCOMES – PROGRESS
REPORT
The Compliance Manager confirmed that the Trust was now registered with
the CQC without conditions having self assessed on the 16 core standards.
She explained that the CQC could either visit the Trust as part of a ‘planned
review of compliance’, a scheduled check of compliance with all 16 core
standards or they could visit the Trust as part of a ‘responsive review of
compliance’, a visit triggered by concerns about a specific area. NonExecutive Director (TB) asked how the new system compared to Standards
for Better Health and the Compliance Manager explained that more detail
was now required and the focus was more outcome based. The CQC would
check on compliance of the core standards via interviews with wards and
staff.
Resolved – that the position be noted.
10.094
THROMBOSIS COMMITTEE (6 MONTHLY) REPORT
The Clinical Effectiveness Specialist presented the Thrombosis Committee 6
Monthly Report to the Committee for information and the Terms of
Reference for approval.
There was a discussion about the new
requirements for all inpatients to be risk assessed in respect to Venous
thromboembolism (VTE). This had been reinforced by the CQUIN VTE
indicator which required that the Trust demonstrated by the end of the
financial year that 90% of inpatients and day cases received a VTE risk
assessment . The AMD for Clinical Governance queried whether it was
appropriate to risk assess cataract day cases and endoscopy cases for VTE.
Á prolonged discussion ensued and there was general agreement that there
were specific procedures that did not require risk assessment for VTE. The
Chairman wanted to know: what was the actual incidence of VTE at the
Trust; how serious was the condition and would risk assessment for patients
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
MINUTE
ACTION
improve patient safety. It was explained that a VTE could be fatal but
precise numbers were unknown and there was little data nationally. It was
agreed that an internal baseline could be extracted from coding within the
Trust and this would be presented to the June meeting by the Director of
Operations. The Committee concluded that the issue needed to be
discussed jointly by clinicians and the Management Board. It was therefore
agreed that the Thrombosis Committee should formulate a recommendation
based on clinical judgement as to which patients could be exempt from VTE
risk assessment.
JI
Ruth
Brown/
Pat Morris
Terms of Reference
It was necessary to amend the Terms of Reference for the Thrombosis
Committee:
a) to reflect the need to implement new NICE guidance for VTE risk
assessment and thromboprophylaxis.
b) Amend the Accountability arrangements to reflect the fact that the
Thrombosis Committee now advised and reported to the Medical Audit
and Operational Governance Group (MAOGG) and SAOGG.
The Terms of Reference were approved by the Committee subject to the
above amendments.
Resolved – that
(A)
(B)
the Report was received and noted and
an internal baseline of VTE incidence (extracted from coding
figures) to be presented at the June meeting
JI
(C)
the Thrombosis Committee to formulate a recommendation Ruth
based on clinical judgement as to which patients could be Brown/
exempt from VTE risk assessment
Pat Morris
the Terms of Reference were approved subject to the
amendments detailed in a) and b) above
(D)
10.095
NHSLA ACTION PLAN FOLLOWING ASSESSMENT IN NOVEMBER
2008
The Compliance Manager presented the Action Plan which resulted from the
Trust’s success in achieving compliance with the Level 2 requirements of the
NHSLA Risk Management Standards for Acute Trusts. She explained that
the NHSLA General assessment for Level 3 had been brought forward to
quarter two 2011/12 in order that it did not coincide with the maternity
assessment. There was concern among the Committee members that there
would be insufficient time to complete the work required. Non-Executive
Director (TB) asked whether there would be sufficient benefit for patients.
The Director of Operations and Nursing highlighted the benefits to patient
safety and service quality along with the financial gains and the general
reputational benefit for the Trust also. The Chairman was unsure that the
Trust had sufficient resources for carrying out the required monitoring and
felt that there was a real risk of failure. It was agreed that a business case SM/PM
should be compiled and presented to Management Board and the decision
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
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as to whether the Trust should be assessed at Level 3 should be considered
there.
Resolved – that,
(A)
(B)
10.096
The report was received and noted and
a business case should be submitted to Management Board
to consider the merits of applying for assessment at Level 3.
SM/PM
PATIENT SAFETY REPORT – Q4 (INCLUDING WORKPLAN)
The Head of Governance presented the Patient Safety Report, including the
Patient Safety Work Programme, to the Committee for information.
Hand Hygiene audits - Non-Executive Director (DD) noted the very positive
performance in the Hand Hygiene Audit Results on page 16 and compared
this to the patients’ perception which was much less positive, as
demonstrated in the national inpatient survey. The Associate Director of
Nursing explained that as well as observational audits, peer audits had been
introduced. A target of 95% compliance had been set and ward managers
were called to account by the Infection Prevention Board if their ward fell
short of this target.
Nurse Care Indicators - Following a question from Non-Executive Director
(AH), there was a discussion about the poor compliance within the Trust with
the Nurse Care Indicators. The target was 95% compliance but was
currently standing at around 80%. Ward Managers falling short of the target
would be required to present action plans at Patient Experience Group.
Missed doses - Non-Executive Director (DD) was concerned at the number
of missed doses due to unavailability of the required drug but the Associate
Director of Nursing felt that more information was needed to assess the
significance of this.
Tissue Viability – Non-Executive Director (AH) noted the increase in the
incidence of pressure sores but the Associate Director of Nursing explained
that the increased incidence was due to an increase in reporting of pressure
sores.
Patient Safety Alerts – The Non-Executive Directors were concerned at the
apparent outstanding actions in response to National Patient Safety Agency
Alerts. They requested that future reports gave more detailed explanation
and identified which Alerts were more significant and suggested that a ‘RAG’ PM
rating would be helpful in ascertaining this.
Resolved – that, future Patient Safety Reports give more explanation
about the Patient Safety Alerts and include a RAG rating so that the PM
significance of the Alerts could be ascertained.
10.097
PATIENT EXPERIENCE REPORT
The Associate Director of Nursing presented the Patient Experience Report
to the Committee for information. The Report had been presented to the
Board of Directors Meeting the previous month.
Patient Advice Liaison Service (PALS) - Non-Executive Director (AH) noted
the increase in PALS contacts when comparing Quarter 1 with Quarters 2, 3
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
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and 4. The Associate Director of Nursing explained that the data was hand
collected and the low figures in Quarter 1 was probably accounted for by the
fact that the PALS Manager was on sick leave during that period.
Telephone performance figures - Non-Executive Director (DD) did not
believe that the figure of approximately 3000 missed telephone calls per
month was acceptable and felt that performance did not compare favourably
with the University of Birmingham. The Director of Operations and Nursing
felt that the overall telephone performance was good and did not believe that
the University of Birmingham was an appropriate comparator. It was agreed JI
that she would present appropriate benchmarking to the Committee in July.
Single Sex Accommodation – there was a discussion about single sex
accommodation and the definition of what constituted a breach of single sex
accommodation.
Non-Executive Director (DD) was disappointed that the Report contained a
number of inaccuracies in figures and graphs which had not been corrected
since the Report had been submitted to the Board of Directors. The Director JI
of Operations and Nursing would liaise with the Associate Director of
Nursing to improve this for future Reports.
Resolved – that, the
(A)
(B)
(C)
10.098
the Report was received and noted
The Director of Operations and Nursing would present JI
appropriate benchmarking of telephone performance at the
July Committee Meeting
the Director of Operations and Nursing would liaise with the JI
Associate Director of Nursing to improve the format of future
Patient Experience Reports.
CQUIN 1 (TISSUE VIABILITY) – PLAN AND REPORTING
The Associate Director of Nursing presented more detail on the
requirements of the CQUIN 1 scheme together with an action plan for
delivering and reporting. CQUIN 1 consisted of 4 elements, the total value
of which was £332,757. Any exceptions would be reported at the Clinical
Quality Review Meeting.
Resolved – that the Report was received and noted.
10.099
CQUIN 2 – PATEINT EXPERIENCE - PLAN AND REPORTING
The Associate Director of Nursing presented more detail on the
requirements of the CQUIN 2 scheme which was a national CQUIN.
Financial payments depended on the results from the annual National
Inpatient Survey and monthly bedside TV surveys. Non-Executive Director
(AH) asked whether Quality Health would continue to conduct the survey
indefinitely and the Associate Director of Nursing explained that it was likely
that this would be reviewed in the future.
Resolved – that the Report was received and noted.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
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10.100
ACTION
FORMATIVE REVIEW OF URGENT CARE SERVICES – FINAL REPORT
The Director of Operations and Nursing presented the Report from the
Formative Review of Urgent Care Services which took place on 4 February
2010 at the Trust. This visit was a precursor to the urgent care review which
took place on 11 and 12 May and a formal report would be received within
the next couple of weeks.
Resolved – that, the Report was received and noted.
Non-Executive Director and Chair (VC) noted, at this point in the
Meeting, that the Committee was no longer quorate.
10.101
CQUIN 3 AND 4 – VTE RISK ASSESSMENT - PLAN AND REPORTING
The Head of Governance presented more detail on the requirements of
CQUINs 3 and 4. She noted that 90% compliance on risk assessment for
VTE for all inpatients would be very challenging for the Trust. Compliance
would be monitored via the Nurse Care Indicators. The Associate Director
of Nursing noted that although VTE risk assessment was measured through
CQUINs this year it would be part of the contract the following year.
Resolved – that the Report was received and noted.
10.102
CQUIN 5 – END OF LIFE CARE PATHWAY - PLAN AND REPORTING
The AGM for Cancer Services presented more detail on the requirements of
CQUIN 5. The financial payment for this scheme was £320K and was
dependent on the number of admitted patients who were identified as ‘end of
life’, following the Liverpool Care Pathway and this needed to be increased
within the Trust. The AGM for Cancer Services explained that a Business
case to expand the palliative care team was being presented to
Management Board at the end of May. The AMD for Clinical Governance
noted the difficulty in identifying which patients were classified as being at
the ‘end of life’.
Resolved – that the Report was received and noted.
10.103
CQUIN 7 – DEMENTIA TRAINING - PLAN AND REPORTING
The Associate Director of Nursing presented in more detail on the
requirements of CQUIN 7. By the end of the year 50% of all patient-facing
clinical staff should receive dementia training appropriate to their job role
and grade. Due to financial constraints it was important to consider
delivering the training in a different way and an e-learning package was
being considered.
Resolved – that the Report was received and noted
10.104
ANY OTHER BUSINESS
There was no further business under this item.
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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting Held on Thursday 13 May 2010
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Resolved – that, the position be noted.
10.105
CONFIDENTIAL MINUTES FROM THE MEETING HELD ON 8 APRIL
10.106
CONFIDENTIAL MATTERS ARISING AND PROGRESS MONITORING
10.107
ACTION PLAN RE: SUI 2009/8651
10.108
UPDATE ON SERIOUS UNTOWARD INCIDENTS (SUI) (CONFIDENTIAL
10.109
DATE AND TIME OF NEXT MEETING
The next meeting will be held on Thursday 10 June 2010 at 12.30 pm in the
Brooke Suite, Warwick Hospital.
Signed
______________________________ (Chair)
Chair of the Clinical Governance Committee
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Date ___________________