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MINUTE of MEETING of the
NHS Board Clinical Governance 17 April 2007 - 9.15am
Board Room, Assynt House
Present: Dr Vivian Shelley, Chair
Mr Ian Gibson
Mr Bill McKerrow
Mrs Heather Sheerin
Ms Heidi May
Also Present: Mr Garry Coutts, Chairman, NHS Highland
Dr Roger Gibbins, Chief Executive, NHS Highland
In Attendance: Ms Elaine Mead, Chief Operating Officer (item 6.1)
Mrs Christine McIntosh, Cancer Network Manager (item 6.1)
Mrs Helen Bryers, Head of Midwifery (item 6.3)
Mrs Gill Keel, Head of Public Engagement (item 7.1)
Dr Lesley Anne Smith, Head of Clinical Governance and Risk
Mrs Mirian Morrison, Clinical Governance Development Manager
Miss Irene Robertson, Board Committee Administrator
Apologies - Dr Eric Baijal, Dr Angus Venters
The Chairman welcomed everyone to the meeting.
2 EMERGING ISSUES
There were no new issues to report.
3 MINUTE OF MEETING HELD ON 16 JANUARY 2007
The minute of meeting held on 16/01/07 was approved.
Working with you to make Highland the healthy place to be
4 MATTERS ARISING
4.1 Caithness Blood Bank
Roger Gibbins gave a brief update, informing the Committee that the service had been
revisited on 12/04/07 and a satisfactory report received enabling NHS Highland to move from
Level 4 to Level 1. Some minor issues remained to be resolved. The report would require to
be ratified by the Inspectorate Board who would then issue a formal letter to NHS Highland
allowing the blood bank service to be re-opened.
The Committee noted progress with the implementation of the recommendations of
the MHRA Report and the satisfactory outcome of the inspection visit.
4.2 Raigmore Mortuary Incident
Lesley Anne Smith advised that the Clinical Governance Support Team were disseminating
information on the issues arising from the incident throughout the organisation via their
newsletter and other appropriate channels. Heather Sheerin summarised the discussion that
took place at the Spiritual Care Committee meeting on 20/03/07, outlining the work done and
the support provided by the Chaplaincy Service. Further discussion was required around
support for bereaved families in situations where organ removal was involved. It was noted
that SSU was giving consideration to incorporating a support role into an existing post. The
Internal Audit Department had been requested to examine the QIS post mortem standards
and policies to identify progress made against the standards. The issues had also been
referred to the Clinical Ethics Committee and the outcome of their discussions was awaited.
Noted the work ongoing to ensure appropriate support mechanisms were in place.
Agreed to ask the Spiritual Care Committee to consider how support might best be
provided to bereaved families specifically when organ removal had been necessary.
4.3 Surgical Profile for NHS Highland
A copy of the response made on behalf of NHS Highland had been circulated. Mirian
Morrison explained that three outliers had been identified:-
The rate of submissions from the Lorn & Isles DGH was lower than the Scottish
average. The issues identified were being addressed and the situation was being
monitored by the Clinical Governance and Risk Management Group within the Argyll
and Bute CHP.
Elective admission mortality rate for surgery at Caithness General Hospital
The rates for the fourth quarter 2004 and the first quarter 2005 appeared to be high.
Additional information was being sought from ISD to ascertain whether the apparently
high mortality rate had continued after this period. Rather than waiting for ISD to
provide information it was suggested that an audit might be undertaken of the cases
during the last two years to see if there were any common underlying factors to
account for the figures.
Elective admissions to general surgery at Raigmore Hospital – mortality rate at 120
The mortality rate at 120 days appeared to be high for Raigmore Hospital. This was
being discussed with the consultants who had requested further information from ISD
to determine whether this was a one year issue or if a trend was developing.
It was proposed that ISD be contacted to confirm how frequently the Surgical Profiles would
be published. It was also proposed that assurances be sought from the clinicians in those
areas where outliers had been identified, that their practice was safe and appropriate. It was
acknowledged that there would be fluctuations in mortality rates but it was important to
ascertain whether there were significant variations. It was therefore proposed that the
Board’s Public Health Team should consider the Profile, identify the factors involved and
determine what would be an acceptable level of variation within the parameters.
Reference was made to some work done by the Public Health Team which had indicated that
Caithness General Hospital appeared to have higher rates for cancer surgery than might be
expected. It was suggested that advice be sought from the Public Health Team on whether
this was an area that required further investigation. In the meantime follow up information
had been requested from ISD.
Noted the actions being taken in respect of the outliers that had been identified..
Remitted to Lesley Anne Smith to obtain the data on which ISD had drawn up the
profile so that a retrospective audit could be undertaken in respect of Caithness
General Hospital but agreed that there should also be a follow up audit.
Agreed that where outliers had been identified an assurance should be sought from
the clinicians that their practice was safe and appropriate.
Agreed to request that the Public Health Team do some further analysis of the Profile
with a view to identifying levels of variation and any trends.
Agreed to have a progress report on the areas under review at the next meeting.
4.4 Incident Management Policy and Procedures
Lesley Anne Smith confirmed that the Incident Management Policy had been discussed and
approved by the Area Partnership Forum at its meeting on 19/01/07 subject to some minor
amendments. The current Incident Reporting Form was being replaced by two reporting
forms, the first to capture the necessary basic information and the second, follow up form to
capture any additional details required. The forms were currently out for consultation.
Training sessions had been organised to introduce the revised procedures to staff, and the
new system was due to go ‘live’ on 01/07/07. It was the intention that all incidents should be
reported, however minor, so that any trends could be identified. The new procedure would
allow the incidents reported to be categorised more precisely but should also encourage near
The Committee noted the progress made with the development of the new policy and
procedures and the timescale for implementation.
5 ASSURANCE AND ACCOUNTABILITY
5.1. Review of Clinical Governance and Risk Management Standards
Lesley Anne Smith informed the Committee that the verbal feedback from the NHS QIS
Review Team had been very positive. Some issues highlighted during the visit had been
incorporated into the Committee’s work plan for 2007-08 and the Clinical Governance
Support Team’s work programme to take forward. It was anticipated that the draft local
report would be received towards the end of May. The Committee noted that QIS had
commissioned an independent consultant to review and evaluate how well the process had
worked. The consultant would be meeting with Board officers to provide feedback in the light
of which the process might be reviewed.
Roger Gibbins advised that a review of regulations and inspections was currently underway
in Scotland and suggested that it might be useful for the Committee to discuss the initial
findings report that had been produced. Other bodies such as Social Work, Education, etc
were subject to extremely rigorous inspection. While the Health Service might not undergo
such an intensive process, the Committee was satisfied that it was sufficiently robust to
provide the necessary assurances. In addition, Health Boards had Non-Executive members
who were appointed by the Health Minister and were accountable. It was also suggested
that the focus of inspections and reviews should be on organisations whose performance
Roger Gibbins referred to the action plan that had been requested following the Board
development session and suggested that it be considered by the Committee prior to its
submission to the Board.
The Committee noted for information a letter from QIS’s Director of Performance
Assessment and Practice Development. The letter provided an update report on review
programmes for the Clinical Governance and Risk Management Standards, together with a
schedule of QIS’s forthcoming activity.
Congratulated the Clinical Governance Team and everyone involved in the process
on the successful outcome of the QIS review.
Agreed that a copy of the initial report of the review of regulations and inspections in
Scotland should be circulated to the members.
Agreed that the action plan developed to move NHS Highland towards achieving
Level 4 would be discussed at the next meeting.
5.2 Clinical Governance and Risk Management Structure and Reporting
Lesley Anne Smith spoke to her report on the clinical governance development session held
in December 2006, describing the outputs of the day and setting out the proposed actions
and suggestions for further development to ensure that clinical governance was embedded in
practice. A revised draft chart was attached to the report which sought to clarify the clinical
governance and risk management reporting structures. In the ensuring discussion the
following points were made.
Consideration required to be given to the role of the Clinical Governance Support
Team in relation to the coordination of clinical governance activities and the support
provided at DHS Management Team level.
Wider discussion was needed on the links between the CHP/SSU Committees and
the Clinical Governance Committee and other standing Governance Committees of
the Board. It was suggested that the Committee should request an annual report
from each of the CHPs/SSU detailing how they have performed against the
standards. It was also suggested that there was some work to be done to formalise
the agendas of the CHP/SSU committees and ensure a degree of consistency across
the operational units.
There was a need for clarification of the assurance role and links between the
organisation-wide groups and committees and the Clinical Governance Committee.
It was suggested that Corporate Services should be included in the chart in the
Operational Management section.
Some services such as OOH and Dental Services were hosted by CHPs and it was
felt that it would be appropriate for them to report through the CHP Clinical
Governance and Risk Management Groups. It was noted that an OOH Clinical
Governance Group had been established which linked in with NHS24 and the
Scottish Ambulance Service. This raised the issue of assurance of governance in
respect of external partnerships and contracts. There was work to be done around
clinical governance and risk management arrangements with the independent sector
but also around Service Level Agreements with other NHS bodies.
Consideration required to be given to where Pharmacy and Facilities sat within the
organisation and their lines of accountability in terms of governance.
Roger Gibbins suggested that some time be devoted at the Corporate Team meeting on
18/04/07 to discuss the model with a view to tightening up the structure and clarifying
reporting arrangements in order to provide managerial operational assurance but also to
avoid duplication of work. Dr Gibbins also advised that he and the Board Chairman would be
visiting the CHPs and would take the opportunity to discuss the clinical governance and risk
management committee structure with a view to clarifying the roles, accountabilities and
relationships of the various committees.
Agreed the areas for further work identified above.
Agreed to discuss the model at its next meeting with a view to further refining it in the
light of the outcome of the discussions with the CHPs.
Gill Keel joined the meeting
The Committee agreed to take agenda item 7 next.
7 HEALTH, WELLBEING AND CARE
The Chairman welcomed Gill Keel, Head of Public Involvement, who updated the Committee
on the following national developments.
(a) Independent Advice and Support Services
Gill Keel outlined the background to this initiative, explaining that the Scottish Executive had
issued a commissioning framework for NHS Boards to procure a defined range of services
under the title of Independent Advice and Support Service (IASS). The purpose of the IASS
was to support patients, carers and the public when making a complaint about NHS services,
and to provide information and support to enable people to make better use of NHS services.
NHS Boards were required to enter into a partnership with a consortium of local Citizens’
Advice Bureaux (CABs) and commission the CABs to provide these services, ensure an
IASS was available to the population living within the Board area, including those who
received services from other Boards, and fund the IASS. Mrs Keel advised that following a
period of negotiation with the CABs in Highland, including Argyll and Bute, NHS Highland
had made a formal offer of additional, phased investment in these new services. The start
date for the first phase of implementation was June 2007, subject to agreement by the CABs,
with a view to full implementation from December 2007. The Board currently invested in a
CAB within Raigmore. Until agreement with the CABs was reached and a formal Service
Level Agreement drawn up, patients wishing to make a complaint were being advised to use
the generic CAB service or other advocacy services. The Committee felt it was important
that complaints should be resolved at local level where possible and to this end the
designated workers in the CABs would need to have direct contact, and work in partnership
with the Board’s complaints team. Mrs Keel proposed to ascertain the position in other
Board areas where the system was already in operation. The Scottish Health Council would
have a role in monitoring performance of the service and ensuring overall compliance with
(b) National Patient Experience Programme
Mrs Keel reported on this initiative which the Scottish Executive had announced in January
2007. The overall aim was to contribute to year on year improvements in the experiences of
patients and carers across Scotland through a programme of patient surveys or
questionnaires. It was anticipated that the first surveys would commence in Spring 2008.
NHS Boards would be contributing to the selection of national topic areas, as well as
supporting the delivery of patient surveys or questionnaires within their own areas. Boards
would also be required to contribute to the costs of the Programme.
The Committee noted the reports and invited Mrs Keel to attend the October meeting
to update the members on progress.
Elaine Mead and Christine McIntosh joined the meeting.
The Committee took Agenda Item 6.1 next
6 SAFE AND EFFECTIVE CARE
6.1 Cancer Waiting Times – Breach Trend Review
The Chairman welcomed Elaine Mead, Chief Operating Officer and Christine McIntosh,
Cancer Network Manager to the meeting. Ms Mead explained that the most recent ISD data
set (July – September 2006) had indicated that more work required to be done in some
specialities in order to ensure a maximum wait of 62 days for treatment for patients who had
been referred urgently by a General Practitioner. An action plan had been drawn up
following the SEHD Cancer Performance Support Team diagnostic visit in December 2006.
Mrs McIntosh reported that good progress was being made against the agreed actions which
were having a beneficial impact on current waiting times. The development of the Cancer
Tracking Tool enabled Patient Targeted Lists (PTL) to be issued to all specialities on a
weekly basis in respect of patients who had been on the Tool for 30 days to ensure that an
early diagnosis was made. Breaches of the 62 day target were reviewed in order to identify
any delay patterns and causal trends which could then be addressed. While the focus was
on the 62 day timeline for urgent GP referrals, the overall aim was to ensure timely diagnosis
and treatment for all patients. In this connection, raising awareness of conditions, screening
and early presentation were all important.
The ongoing refinement of information enabled more detailed analysis to be undertaken.
The consistent, pro-active approach adopted for breach and potential breach review
involving local clinical and management teams enabled any problem themes to be identified
and appropriate action to be taken.
Noted the systems in place to identify and take remedial action on the underlying
trends of patient delays and breaches of the 62 day cancer pathway.
Agreed that the detailed scrutiny being undertaken of patient pathways provided the
necessary assurance that the issues identified were being addressed.
Agreed to receive further updates on progress against the action plan and
information on any trends or breaches of the 62 day pathway.
Ms Mead and Mrs McIntosh left the meeting
The Committee returned to the agenda
5.3 Draft Committee Work Plan 2007 - 2008
There was tabled progress report on the Committee’s work plan for 2006-07 noting the status
of the various actions, together with a draft work plan for 2007-08. Lesley Anne Smith
explained that the latter contained some outstanding actions from the 2006-07 work
programme, and some areas that had been highlighted during the NHS QIS Review of
Clinical Governance and Risk Management Standards in March had also been incorporated
in the draft. The next step would be to develop a more detailed work programme and action
plan to support it.
The Committee agreed the draft work plan for 2007-08, noting that it would be further
refined in the light of formal feedback from the NHS QIS review visit and that a more
detailed version would be submitted to the next meeting.
5.4 Clinical Governance and Risk Management Performance Report
The Committee received the performance report prepared for the March Board meeting and
the draft report which would be submitted to the May Board, detailing performance against
complaints targets, performance in relation to patient safety, embedding clinical governance
and risk management across the operating units, and the NHS QIS review of the clinical
governance and risk management standards. It was felt that the Committee would be an
appropriate forum in which to debate the reports. Lesley Anne Smith asked the Committee
to consider the information it would like the Clinical Governance Support Team to provide in
the reports but also the format of the reports that should go to the Board. Discussion
followed on how the information in the reports was cascaded throughout the organisation and
what mechanisms existed for ensuring that recommendations were implemented at
operational level. Noting that the performance reports were included on the agenda of the
DHS Management Team meetings where they were discussed by the CHP/SSU General
Managers and Clinical Directors, the Committee felt that this made explicit their responsibility
for taking back the information to their units, feeding it into their clinical governance
structures and ensuring that action was taken as appropriate. The Clinical Governance and
Risk Management Support Team produced a newsletter and also had a web page, and
consideration could be given to maximising the use of these channels to disseminate
relevant information on clinical governance and risk management issues. The Scottish
Ombudsman Commentaries were circulated to the operational units and disseminated further
via the Intranet to ensure that recommendations and lessons learnt were cascaded through
Noted the arrangements in place for disseminating the clinical governance and risk
management performance reports.
Agreed that further consideration needed to be given to reporting mechanisms to
ensure that recommendations were implemented and follow up action taken as
Agreed that the performance reports would be submitted to the Committee for
discussion but that a report would also be prepared to keep the Board informed of
significant clinical risks to the organisation.
5.5 Research Governance and Research Ethics Committee Update
There had been circulated report by Dr Catherine Sinclair, NHS Highland Research
Manager, advising that the research governance self assessment questionnaire had been
completed and submitted to the Chief Scientist Office. A response had subsequently been
received confirming that on the basis of the information provided the Chief Scientist Office
was satisfied that NHS Highland was meeting the research governance standards. Some
areas were under further development including audit arrangements, adverse events
reporting, consumer involvement in research, and a current research page on the NHS
Highland Internet site. Progress on these areas would be detailed in the next research
governance compliance report.
With regard to the revised Research Ethics Committee structure, an information day had
taken place on 22/03/07 to inform potential applicants to the Ethics Committee of the
establishment of a North of Scotland Research Ethics Committee encompassing NHS
Grampian, Highland, Orkney, Shetland and Western Isles and the arrangements for the new
committee which became operational at the beginning of April.
Noted that NHS Highland was meeting the agreed research governance standards.
Agreed to request a report from Dr Sinclair detailing the areas for development and
the further work that required to be done.
Noted the establishment of a North of Scotland Research Ethics Committee and its
5.6 NOSCAN Clinical Governance Policy
NOSCAN had recently updated its clinical governance policy, copy of which had been
circulated. Before asking NHS Board Clinical Governance Committees to endorse the
document, NOSCAN was seeking to assess the state of cancer clinical governance and the
application of its policy within NHS Boards by means of a questionnaire for completion by
Clinical Governance Committees. NOSCAN may revise the policy in the light of feedback
from the questionnaire.
Noted the updated policy.
Remitted to Lesley Anne Smith to follow up on the questionnaire and report back to
the Committee at the next meeting.
6 SAFE AND EFFECTIVE CARE
6.1 Cancer Waiting times – Breach Trend Review
Helen Bryers joined the meeting
6.2 Caithness Maternity Services Update
The Chairman welcomed Helen Bryers, Head of Midwifery who spoke to her progress report
on the review of the arrangements for implementation of the National Framework for
Maternity Services and the Expert Group on Acute Maternity Services (EGAMS). The
Committee noted the areas with ‘Red’ and ‘Amber’ status for further development. The NHS
QIS review of maternity services in Highland had highlighted a number of unmet standards,
some of which pertained to the service at Caithness General Hospital in particular. The
Board Nurse Director was leading the QIS Maternity Standards Sub Group of the Women’s
Health Network which had begun work on the unmet standards. Maternity services
guidelines for clinical practice were in place in the Caithness maternity unit. The midwifery
project group was working towards implementation of an agreed new integrated midwifery
model of care for Caithness which would integrate the hospital and community services,
provide a flexible workforce and midwives with skills and competencies required of a
midwife-led service. The role of Lead Midwife was about to be advertised. There was an
issue around remote and rural services generally which would need to be fed into the work
currently being done on Rural General Hospitals with a view to informing the development of
safe and sustainable models of maternity care.
Mr McKerrow sought an assurance that women at higher risk who opted to stay in Caithness
were fully informed of the limited clinical service that could be provided there should
complications occur. For example, there were no NICU facilities or dedicated obstetric
anaesthesia. He suggested that a consent form, modified as appropriate, might be
introduced to ensure that potential risks had been discussed with the women.
In summary, implementation of the National Framework and EGAMS was well underway and
steady progress was being made. There were still some areas that required further work,
and this would be led locally by the Caithness Maternity Action Team and overseen by the
NHS Highland Women’s Health Network.
Noted progress against the implementation of the Framework and the areas where
more work required to be done.
Agreed to receive a further report at its meeting in October to be assured that the
risks identified were being managed and that progress continued to be made towards
developing a safe and sustainable maternity service.
6.3 Women’s Health Network
This was deferred to the next meeting.
6.4 Anticoagulation – related clinical governance issues for NHS Highland
It was agreed that Mirian Morrison would give a report to the July meeting.
6.5 Safer Patient Initiative
NHSScotland had set up a Patient Safety Alliance to build on and develop the Delivering for
Health patient safety strand. A Specification for Programme Development had been drawn
up setting out the aims and objectives of the Programme. On behalf of the Patient Safety
Alliance NHS QIS was inviting the submission of proposals from suitably experienced
individuals and organisations to support the development and implementation of the
Programme which would cover all hospitals in Scotland.
The Committee noted the launch of this initiative and the work ongoing to develop and
implement the Programme.
7 HEALTH, WELL-BEING AND CARE
Discussed earlier in the meeting.
8 FOR INFORMATION
The following minutes/documents were submitted for the Committee’s interest and
Risk Management Steering Group (08/02/07)
Risk Register February 2007
Area Drug and Therapeutics Committee Minute of Meeting of 30/01/07
9 DATE OF NEXT MEETING
The next meeting would be held on Tuesday 17 July 2007 in the Board Room, Assynt House
The meeting concluded at 1.00 pm