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12 May 2010                               Typetalk: Tel 0800 959598
                                          www.nhshshighland.scot.nhs.uk


            MEETING OF NHS BOARD CLINICAL GOVERNANCE COMMITTEE

                            Tuesday 18 May 2010 at 9.15am
                         Board Room, Assynt House, Inverness

                                    AGENDA

9.15    1         WELCOME / APOLOGIES


9.20    2         EMERGING ISSUES


9.25    3         MINUTE OF MEETING HELD ON 9 FEBRUARY 2010 (attached)

                  The Committee is asked to approve the Minute



9.30    4         MATTERS ARISING

        4.1       Update on previously raised emerging issues

        4.1.1     Interim arrangements to cover Head of Clinical Governance & Risk
                  Management’s leave

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


9.40    4.2       Review of Committee’s Effectiveness
                  Report by Internal Audit and Action Plan (previously circulated)

                  The Committee is asked to note the report and agree the areas for
                  action


10.10   4.3       Clinical Governance Committee Action Plan – Update
                  Report by Lesley Anne Smith, Head of Clinical Governance & Risk
                  Management (attached)

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




                Working with you to make Highland the healthy place to be
        5       ASSURANCE AND ACCOUNTABILITY

10.10   5.1     Clinical Governance Committee Annual Report 2009 – 2010 (attached)

                The Committee is asked to approve the content of its Annual Report
                2009 – 2010 for submission to the Audit Committee on 25 May 2010.


10.15   5.2     Clinical Governance Committee Draft Work Plan 2010 – 2011
                (attached)

                The Committee is asked to discuss and agree its work plan for 2010 –
                2011.


10.25   5.3     Clinical Governance Forum Update
                Report of meeting held on 3 March 2010 (minute attached) and on 17
                May 2010

                The Committee is asked to note the report of the meeting held on 3
                March 2010 and the current position in relation to issues previously
                identified.


        5.4     Infection Control Issues

10.35   5.4.1   Clinical Governance and Infection Control Structures and Reporting
                Arrangements
                Report by Heidi May, Nurse director (to follow)

                The Committee is asked to consider and agree the structures and
                reporting arrangements


10.50   5.4.2   Health Facilities Scotland Control of Infection Report
                Report by Heidi May (to follow)

                The Committee is asked to note progress against implementation of
                the report’s recommendations


11.00   5.5     Slips, Trips and Falls – Development of Falls Prevention Strategy
                Report by Iain Macritchie, Rehabilitation Coordinator, on behalf of
                Judith Catherwood, Associate Director (AHPs)

                The Committee is asked to:
                    Note the report
                    Note the rolling out of the MORSE Risk Assessment Training for
                      identifying those at risk of falling in the In-Patient settings of NHS
                      Highland
                    Endorse the early completion of this roll out and its link with Clinical
                      Quality Indicators
                    Endorse the need to change staff and population attitudes (which
                      wrongly perceive falls in our hospitals, care homes and
                      communities as inevitable and not preventable) by supporting the
                      robust implementation of the Falls Prevention and Bone Health
                      Strategy and anticipating a reduction in the number of injurious falls
                      across NHS Highland
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                      Encourage the early identification of those who have fallen and
                       been taken to an emergency department
                      Encourage the Board-wide implementation of good Fracture
                       Liaison practice in order to prevent subsequent falls with escalating
                       severity of fracture
                      Specify any additional actions pertaining to Clinical Governance
                       arising from the report


11.15   5.6     Information Governance
                Verbal update by Mirian          Morrison,    Clinical   Governance     and
                Development Manager

                The Committee is asked to note the position


11.20   5.7     Complaints Policy and Procedures
                Report by Lesley Anne Smith (attached)

                The Committee is asked to approve the attached Complaints
                Management Policy and Procedures


11.30   5.8     Pregnancy and Newborn Screening Programmes in NHS Highland:
                Annual Reports 2008 and 2009
                Report by Sally Amor, Child Health Commissioner/Public Health
                Specialist on behalf of Margaret Somerville, Director of Public Health
                and Health Policy (attached)

                The Committee is asked to:
                    Note the attached Pregnancy and Newborn Screening Programmes
                      Annual Report for 2008 and 2009
                    Note the key issues and issues that have been identified in the
                      preparation of this report with regard to quality assurance and
                      clinical governance
                    Endorse the report and the proposals for future annual reports to
                      be presented to the Clinical Governance Committee in the autumn
                      to allow for the presentation of a full year of data from the preceding
                      year



        6       SAFE AND EFFECTIVE CARE

        6.1     NHS Quality Improvement Scotland (NHS QIS)

11.40   6.1.1   Forthcoming NHS QIS Review Visits
                Verbal Report by Mirian Morrison

                The Committee is asked to note progress in preparations for the NHS
                QIS reviews.


        6.1.2   Update on recent review visits




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11.45         (a) Clinical Governance and Risk Management Standards Review
                  Verbal report by Lesley Anne Smith

              The Committee is asked to note the report of the NHS QIS visit on
              10/11 March 2010.


11.55         (b) Food, Fluid and Nutrition
                  Report by Judith Catherwood, Associate Director (AHPs) and
                  Executive Lead for Food, Fluid and Nutritional Care

              The Committee is asked to:
                  Note progress with implementation of the FFNC standards in
                    Hospitals within NHS Highland
                  Note NHS Highland’s local report from the QIS visit from March
                    2009 which was published in February 2010 along with the national
                    overview
                  Note the publication of Health Facilities Scotland national report in
                    March 2010 on Boards’ implementation of the National Nutrition
                    Specification, NHS Highland’s compliance rate of 89.5% and future
                    plans to improve our compliance with the specification
                  Note progress towards achievement of the targets, standards and
                    national nutrition specification across NHS Highland
                  Endorse the priorities for future work to ensure NHS Highland
                    complies with the FFNC standards and the National Nutrition
                    Specification


12.05   6.2   Risk Management Steering Group
              Report of review of the Group’s structure and remit
              Verbal update by Lesley Anne Smith

              The Committee is asked to note the position


12.15   6.3   Surgical Profiles – progress against action plan (attached)
              Report by Lesley Anne Smith

              The Committee is asked to note the submission of the updated Action
              Plan

12.25   6.4   NHS Highland Response to Mid Staffordshire NHS Foundation Trust
              Reports
              Report by Lesley Anne Smith (attached)

              The Committee is asked to discuss the recommendations made by
              the Independent Inquiry and consider what further actions may be
              required by NHS Highland in response to these



        7     HEALTH, WELLBEING AND CARE

              There are no items under this heading, the report on the Independent
              Advisory and Support Service having been deferred to the next meeting



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12.40   8    FOR INFORMATION (attached)

                a) North Highland CHP Clinical Governance & Risk Management
                   Group minutes of 26/01/10
                b) Mid Highland CHP Clinical Governance & Risk Management Group
                   minutes of 10/03/10
                c) Raigmore Hospital Clinical Governance & Risk Management Group
                   minutes of 20/01/10 and 17/02/10
                d) Risk Management Steering Group minutes of 18/03/10
                e) Area Drug & Therapeutics Committee minutes of 20/01/10
                f) Maternity Services Committee minutes of 15/02/10
                g) Information Governance Committee minutes of 19/04/10

             The Committee is asked to note the Minutes



        9    ANY OTHER COMPETENT BUSINESS


        10   DATE OF NEXT MEETING
             The next meeting of the Committee will be held on Tuesday 17 August
             2010 at 9.15am in the Board Room, Assynt House


13.00        CLOSE OF MEETING




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