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					                                            Assynt House
                                            Beechwood Park
                                            Inverness, IV2 3BW
                                            Telephone: 01463 717123
                                            Fax: 01463 235189
                                            Textphone users can contact us via
6 November 2009                             Typetalk: Tel 0800 959598
                                            www.nhshshighland.scot.nhs.uk




           MEETING OF NHS BOARD CLINICAL GOVERNANCE COMMITTEE

                          Tuesday 10 November 2009 at 9.15 am
                          Board Room, Assynt House, Inverness

                                      AGENDA
1       WELCOME/APOLOGIES


2       MINUTE OF MEETING HELD ON 18 AUGUST 2009 (attached)

         The Committee is asked to approve the Minute.



3       EMERGING ISSUES


4       MATTERS ARISING

4.1     Update on previously raised emerging issues

4.1.1   Radiological Investigation at Lorn & Isles Update
        Ian Bashford, Medical Director

4.1.2   Pandemic Flu update
        Ken Oates, Interim Director of Public Health

4.1.3   Caithness Maternity Services update
        Heidi May, Nurse Director

        The Committee is asked to note the current position in relation to outstanding
        investigations and other emerging issues.


4.2     Clinical Governance Committee Action Plan – Update
        Report by Lesley Anne Smith, Head of Clinical Governance & Risk Management
        (attached)
         Record Keeping Audit – Roll out of audit tool
         Clinical Ethics Committee – Reporting Arrangements
         Surgical Profiles – update on Action Plan

        The Committee is asked to note progress against the action plan.



               Working with you to make Highland the healthy place to be
4.3     Clinical Governance Forum update
        Verbal report by Ian Bashford

        The Committee is asked to note the feedback from the first meeting of the
        Clinical Governance Forum held on 22nd September 2009.



5       ASSURANCE AND ACCOUNTABILITY

5.1     Clinical Governance and Risk Management within Operational Units
        Report on current issues within the Mid Highland CHP by Gill McVicar, General
        Manager, Dr Angus Venters, Clinical Lead, and Alison Hudson, Lead Nurse

        The Committee is asked to note the issues raised in the Report.


5.2     Clinical Governance and Risk Management Performance Report
        Report by Lesley Anne Smith (attached)

5.2.1   Report on Medication Incidents
        Report by Lesley Anne Smith (attached)

        The Committee is asked to note the contents of the reports and the proposed
        actions to address medication incident within NHS Highland.


5.3     Clinical Governance Work Programmes 2009-10
        Update by Mirian Morrison, Clinical Governance Development Manager

        The Committee is asked to note progress against the Clinical Governance
        Support Team Work Programme and the Clinical Governance Committee Plan
        for 2009-10.


5.4     Infection Control

5.4.1   Clinical Governance and Infection          Control   Structures    and   Reporting
        Arrangements
        Report by Heidi May (to follow)

        The Committee is asked to approve the proposed structures and reporting
        arrangements between Infection Control and Clinical Governance

5.4.2   Health Facilities Scotland Control of Infection Report
        Report by Heidi May (attached)

        The Committee is asked to note the report for information and assurance
        around actions.


5.5     Area Drug and Therapeutics Committee Annual Report
        Report by Sharon Pfleger, Consultant in Pharmaceutical Public Health (attached)

        The Committee is asked to note the annual report from the Area Drug and
        Therapeutic Committee and its Sub-groups together with proposed areas of
        activity for 2009-10.
                                             2
5.6     Information Governance

5.6.1   Information Governance Standards
        Six-monthly progress report by Bill Reid, Head of EHealth (attached)

        The Committee is asked to note progress on Information Governance
        Standards and feedback received from Information Services Division (ISD)


5.6.2   Information Security at Closed Sites
        Update on Protocol by Bill Reid (attached)

        The Committee is asked to note the Protocol.


5.7     Maternity Services Committee Update
        Report by Heidi May, Nurse Director (attached)

        The Committee is asked to note the progress made by the Maternity Services
        Committee in delivering a Highland-wide approach to the delivery of maternity
        care provision


5.8     Local Supervisory Authority Midwifery Officer (LSAMO) Annual Report
        Report by Mary Vance, LSAMO (attached)

        The Committee is asked to note the Report


5.9     Internal Audit Reports (attached)
         Referral Process to Secondary Dental Care
         Review of Nursing, Midwifery and Allied Health Professional Registrations
            Report by Heidi May, Nurse Director (attached)
         Caithness General Hospital Review
         Review of Radiology Waiting List Initiative – Follow-up

        The Committee is asked to note the outcome of the audits


5.10    Cervical Screening Programme: A Triennial Report 2006 - 2008
        Report by Susan Vaughan, Directorate of Public Health (attached)

        The Committee is asked to note the report



6       SAFE AND EFFECTIVE CARE

6.1     Draft Quality and Patient Safety Framework
        Report by Lesley Anne Smith (attached)

        The Committee is asked to note progress with the development of the Quality
        and Patient Safety Framework.




                                              3
6.2     Draft Incident Management Policy and Procedures
        Report by Mirian Morrison (attached)

        The Committee is asked to consider and agree the Draft Policy and Procedures


6.3     NHS Quality Improvement Scotland (NHS QIS)

6.3.1   Forthcoming NHS QIS review visits and update on recent visits
        Verbal report by Mirian Morrison, Clinical Governance Development Manager

        The Committee is asked to note progress in preparations for the NHS QIS
        reviews and the outcome of recent visits


6.3.2   Clinical Governance & Risk Management Standards Review
        Report by Lesley Anne Smith (attached)

        The Committee is asked to note progress in preparation for the forthcoming
        NHS QIS review


6.4     Risk Register

6.4.1   Report on audit of Decontamination Standards
        Report by Douglas Seago, Head of Facilities Management (attached)

        The Committee is asked to note progress against the Decontamination
        Standards and the actions taken to reduce the risks



7       HEALTH, WELLBEING AND CARE

7.1     Better Together Patient Experience Programme
        Update by Heidi May

        The Committee is asked to note the position in relation to the roll out of the
        national patient experience programme


7.2     Draft Patient Information Policy
        Report by Mirian Morrison (attached)

        The Committee is asked to consider and agree the Draft Patient Information
        Policy.


7.3     Draft Being Open Policy
        Report by Mirian Morrison (attached)

        The Committee is asked to consider and agree the Draft Being Open Policy.




                                               4
7.4       Draft Policy For Consent to Treatment, Surgery and Invasive Procedures
          Report by Lesley Anne Smith (attached)

          The Committee is asked to consider and agree the Draft Consent Policy.



8         FOR INFORMATION (attached)
         Maternity Services Committee minutes of 17/08/09
         Control of Infection Committee minutes of 09/09/09
         Clinical Governance Forum minutes of 22/09/09

          The Committee is asked to note the reports



9         ANY OTHER COMPETENT BUSINESS


10        DATE OF NEXT MEETING

The next meeting of the Committee will be held on Tuesday 9 February 2010 at 9.15am in
the Board Room, Assynt House.




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