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AGENDA ITEM NUMBER 12 Powered By Docstoc
					                                                                    AGENDA ITEM NUMBER: 12

REPORT TO:                     Trust Board
DATE OF MEETING:               2 June 2009

TITLE :     Clinical Governance Committee Core Brief (April 2009)                    DOC DATE:       May 2009


HCC Trust Closure Letter – Community Circumcisions
Concerns raised by Consultant of the Trust regarding the treatment of four patients who had previously undergone
religious circumcision in the community. These concerns were escalated to the Healthcare Commission as well as
internally within the Trust. Each case investigated locally and discussed with the SHA and relevant PCT.

The Trust were asked by the Healthcare Commission to provide assurances on how these had been managed.
Evidence had been provided and this letter was formally acknowledging the closure of the issue. It was noted that
the issues raised re: religious circumcision and the commissioning of these services were national and the
responsibility of Commissioners to resolve.

The Committee noted the Healthcare Commission’s letter and findings.

Lead: Robert Courteney-Harris, Medical Director
Ext:   (55) 5414

Update Report: Privacy & Dignity – Mixed Sex Accommodation
The report provided an update on the actions that have been undertaken relating to the elimination of mixed sex
accommodation since May 2008. The report also summarises the Department of Health position and sets out their
expectations on the elimination of mixed sex accommodation.

The result of the latest audit undertaken by the Patient Advice and Liaison (PALS) team is also included in the
report, which demonstrates an overall improvement in the number of single sex wards at University Hospital of North
Staffordshire. Supporting measures are being set up and there was a £100,000,000 fund available. The Trust
submitted a bid and been awarded £250,000.

The Committee noted the report and agreed the suggested way forward.

Lead: Julie Smith, Assistant Director of Nursing
Ext:   (55)

Agenda item 12.doc                                                                                       Page 1 of 8
Maternity Action Plan
This document provides an update for maternity services within UHNS on the following documents:-
 • CEMACH (2008). Why Children Die. A pilot study 2006. May 2008
 • CEMACH (2007). Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer 2003 – 2005.
     December 2007
 • DOH (2007). Maternity Matters: Maternity Matters: choice, access and continuity of care in a safe service. April
 • DOH (2004) National Service Framework for Children, Young People and Maternity Services: Maternity
     Services. September 2004
 • DOH (2007) “Safer Childbirth: Minimum Standards fro the Organisation and Delivery of Care in Labour”.
     October 2007
 • Healthcare Commission Report: Review of Maternity Services UHNS (2007)

The Committee will continue to monitor progress against the action plan.

Lead: Dymphna Sexton-Bradshaw, Professional Head of Midwifery
Ext:   72101

Midazolam Action Plan
This Action plan was devised in response to NPSA Rapid Response Report No.11 – Reducing Risk of Overdose
with Midazolam Injection in Adults.

ST went through the Action Plan and stated that at present they are working with areas where this is used and
looking at Risk Assessments in areas where they are needed. There were three identified Clinicians drawing up the
guidelines and these are expected to be circulated by the end of May to ensure that they are ready in time to be
taken to the Safe Medications Group. The areas where Midazolam is used can be ascertained through the
Pharmacy computer system.

There has been an audit of Flumazenil, which is needed where Midazolam is stored and can be used as a marker of
excessive dosing. There will be a six month review of this.

Once guidelines are agreed by all Divisions and ratified by Clinical Governance responsibility for this needs to be
assigned by Trust senior management, the NPSA expect this to be to a Consultant Anaesthetist. This is an
organisational issue and ST agreed to approach and link in with the Clinical Director for Anaesthetics, Dr Vijay
Jeganath. This Action Plan will be brought back to the Committee in June.

The Committee noted the content of the Action Plan and the actions to be taken.

Lead: Sue Thomson, Clinical Director of Pharmacy
Ext:   (55) 2900

EIDO Patient Leaflets Update
An options paper was circulated and the Committee was asked to consider the renewal of the three year EIDO
contract and also a relaunch of these leaflets within the Trust.

A relaunch package will be brought to the Committee in June confirming proposals on informing clinicians about the
leaflets and range available.

The Committee noted the content of the update with positive reviews and agreed a way forward.

Lead: Mary Moss, Clinical Governance & Risk Manager
Ext:   (55) 5382

Agenda item 12.doc                                                                                       Page 2 of 8
Information Governance Assessment/Performance Report
The “Information Governance Report 2008- 2009 was presented. CW explained that the report outlined some of the
key Information Governance achievements during 2008/09. The report also contained the results of the Trust’s
2008/09 IG assessment; for the first year the outcome of this assessment will be shared with the Audit Commission.
Whilst the overall 2008/09 result of 70% (GREEN) was equal to that of 2007/08; there have been +/- movement
within the individual components.

During in April/May 2009, CW & the Information Governance Steering Group would produce a series of IG
improvement plans and report back to the CGC in June.

The Committee noted the contents of the report.

The proposal was endorsed by the Committee.

Lead: Cathryn Warwick, Information Governance Manager
Ext:   (55) 4040

HCC Reports: Safe in the knowledge and Safely Does It – UHNS Response
The Healthcare Commission has published two reports relating to Safety and Board leadership. A number of
recommendations have arisen from both documents, which have been included in the gap analysis and action plan.
The Trust is largely compliant with the recommendations but it is acknowledged that some further work is required
around the following areas;

•   Review of the type of patient safety information received at Board level.
•   Ensuring lessons learned are fed back to staff on the ground floor

These areas had already been identified as potentially weak and so it was intended that the development of the
Clinical Governance, Audit & Risk Strategy would address this.

At present the RCA tool is being looked at following the NPSA releasing information nationally. CR is also looking
into building something into Datix to allow reports to be generated and feedback to ground floor staff to be carried
out. The focus is on lessons learnt and JM is currently liaising with the PCTs on this. A report will be brought to the
Committee in a few months time and this will also be taken to the Governance and Risk Committee and the Trust

The Committee noted the content of the report

Lead: Claire Rylands, Clinical Governance, Audit & Risk Development Manager
Ext:   (55) 4152

Agenda item 12.doc                                                                                          Page 3 of 8
NPSA RRR001 – Patients Undergoing Hip Arthroplasty fro Fractures – UHNS Update
An alert was issued by the National Patient Safety Agency on 11 March 2009, with actions for completion by 14
September 2009.

The Clinical Governance Committee were assured that the Trust is in a good position in relation to this alert. There
is a lead clinician in this area, Mr Phil Roberts, and practice is recognised to be more advanced than it is nationally.
Mr Roberts has been in liaison with the NPSA in relation to this alert.

An action plan has been developed, which requires the support of the Clinical Governance Committee for a business
case to recruit part time administrative support, to ensure that the Trust fulfils its national data submission

Mr Roberts will bring a formal document to the Committee in a few months time.

The Committee received and noted the report.

Lead: Claire Rylands, Clinical Governance, Audit & Risk Development Manager
Ext:   (55) 4152

National COPD Report
UHNS has taken part in two large audits of COPD care. That of the Royal College of Physicians / British Thoracic
Society / British Lung Foundation identified that we provided a good level of care in areas where we could influence,
but care was poor where PCT involvement was required.

It was reported that a meeting with the PCTs would take place within the next three weeks and they would want to
sign off the level agreement by June, following which the Committee would receive a further update from the lead

The Committee received and noted the report.

Lead: Martin Allen, Consultant
Ext:   (55)

Triage Flow Charts
The flowcharts have been agreed by the wider team and a pilot is underway in A&E. A formal report will be
produced for the Committee and this item will be brought back in June

Lead: Claire Kelsall
Ext:   (55)

Agenda item 12.doc                                                                                           Page 4 of 8
Monthly Infection Control Report
This paper is written to provide information about the progress with HCAI management and reduction within UHNS
and the progress, delivery and action of staff against the Infection Prevention and control /HCAI local and national

This report outlines the activities of the Trust relating to infection prevention and control for March 2009. It indicates
how the Trust has the relevant practices and procedures in place to ensure the early identification of patients with
infections and or colonisation of infection. It describes progress with audit, surveillance, education and training, and
with the implementation of new interventions relating to infection prevention and control within UHNS and the wider
Health Economy.

Lead: Helen Jenkinson, Deputy Director of Infection Prevention and Control
Ext:   (55) 4282

MRSA Screening Assurance Framework
This paper was written to provide information about the progress against the DH requirement that all relevant
elective admissions are screened for MRSA starting 1 April 2009.
Elective screening should be in place all admissions from the 1              April and the continuation of screening of
emergency admissions, which has been ongoing since May 2008.

A leaflet was circulated on MRSA and MRSA Screening and the Committee were informed that this is available on
the intranet

The Committee received and noted the documentation provided

Lead: Helen Jenkinson, Deputy Director of Infection Prevention and Control
Ext:   (55) 4282

Agenda item 12.doc                                                                                             Page 5 of 8
UHNS Report on Death at Alexandra Hospital and Remedial Actions
This is a report on a serious incident involving a patient at Alexandra Hospital who was referred from Royal
Shrewsbury Hospital (RSH) NHS Trust in 2007. Due to operational factors at the University of North Staffordshire
(UHNS) Trust he was offered his surgery at another centre, the BMI Alexandra Hospital, Cheadle. The inquest was
widely reported in the press at the local and national level. The coroner has written to the Chief Executive of the
Alexandra Hospital (under Rule 43 Coroners Rules 1984) asking for a full report as to the incident and the measures
that the Alexandra Hospital is going to take to ensure that this unfortunate event is not repeated.

The CEO of UHNS requested a review to be undertaken which was to focus on patient safety issues at the
Alexandra to include:
    Information given to patients regarding the Unit at which they are to receive treatment
    Information contained within Service Level Agreements (SLA’s) regarding communication between organisations
    regarding Mortality data and Adverse incidents
    The process of escalation within UHNS following receipt of records [from treating unit] of patients where a
    serious event or death occurs.

The paper reports on the outcome of the UHNS review and the actions to be taken to reduce the potential of similar
events reoccurring. However, the review identified areas of good practice and cardiac service was found to be of
high quality with good results. A formal action plan will be submitted in June to ensure that all actions that need to be
completed are undertaken.

The Committee noted the report and agreed the way forward

Lead: Lyn Ford, Clinical Governance, Audit & Risk Manager
Ext:   (55) 5155

An update was circulated to update the Committee on the NCEPOD outstanding actions from the reports received
since 2002.

The Committee noted the update for information and requested that this be brought back in June to include the late
received comments.

Lead: Mary Moss, Clinical Governance & Risk Manager
Ext:   (55) 5382

Critical Care Network Action Plan Update
The Action Plan had been developed in response to the recommendations made in the jointly commissioned North
West Midlands Critical Care Network Review Report, received in November 2008. The document lists all the
recommendations and identifies the Executive Lead for each action as well as summarising the current position /
action required and completion dates.

This has been recently updated and the most up to date version, Version 4.

The Committee noted and received this Action Plan and requested regular updates on it’s progress

This was approved by the Committee.

Lead: Jamie Maxwell, Deputy Clinical Governance, Audit & Risk Manager
Tel:   (55) 4251

Agenda item 12.doc                                                                                            Page 6 of 8
Clinical Governance Committee Terms of Reference and Membership Annual Review
The Committee were unable to approve this item as they were not quorate and asked that it be brought back to the
May Committee meeting.

Lead: Jamie Maxwell, Deputy Clinical Governance, Audit & Risk Manager
Tel:   (55) 4251

Dr Foster Mortality Reports
The Committee were provided with examples of mortality reports for inclusion in future performance and quality &
safety reports to inform the Trust Executive & Non Executives of current mortality figures.

Agreements were made on the content and layout of the information required and agreed to bring a report to the
meeting in June.

Lead: Jamie Maxwell, Deputy Clinical Governance, Audit & Risk Manager
Tel:   (55) 4251


•    Trust Strategic Objectives - Excellence in Healthcare
•    Annual Healthcheck Declaration Core Standards
•    NHSLA Standards

3.    RECOMMENDATIONS             (To Note/Receive/Endorse/Adopt/Defer etc)

To receive this summary report.

4.                     AUTHOR                        OPERATIONAL LEAD                 EXECUTIVE LEAD
NAME                 Jamie Maxwell                Jamie Maxwell/Various Leads        Rob Courteney-Harris


Delivery of an effective clinical governance framework within the Trust.

      Yes                    No              Corporate                               Divisional
      If no, rationale:

      If so, what level of Residual Risk has been allocated?
             Consequence                  Likelihood                Risk Score              Level of Risk

      Risk Description:

      Please refer to individual assessments within Datix.

7. TO BE CONSIDERED AT:              TRUST BOARD               EXEC         GOVERNANCE &            OTHER
                                                             COMMITTEE          RISK               (STATE)

Agenda item 12.doc                                                                                    Page 7 of 8
Approved/deferred/received        May 2009                           May 2009

8. HAVE ALL IMPLICATIONS BEEN      YES    NO     N/A                            YES   NO     N/A
FINANCE                             √                  DIVERSITY IMPACT          √
NATIONAL POLICY/LEGISLATION         √                  IM&T                      √
LDP                                 √                  CLINICAL RISK             √
HR                                  √                  GOVERNANCE                √
CONSULTATION                        √                  OTHER

Glossary of terms

                      No ambiguous terms used.

Agenda item 12.doc                                                                    Page 8 of 8