snbts management board - Scottish National Blood Transfusion ...

FINAL VERSION
B 11.96
SNBTS MANAGEMENT BOARD
Training Room, Ellen’s Glen Road, Edinburgh
Tuesday, 10 TH May 2011
Present:
Martin Bruce (MB)
Bruce Cuthbertson (BC)
Janine Emerson (JE)
Peter Forsyth (PF)
Robin Fraser (RF)
Linda Lodge (LL)
Lynne Kidd (LK)
Apologies:-
Irene Barkby (IB)
George Galea (GG)
Rachel Green (RG)
In attendance:-
Yvonne Todd (YT)
Jacqueline Millar (JM)
Safia Qureshi (SQ)
Keith Thompson (KT) (Chair)
Bert Stillie (BS)
Hazel Thomson (HT)
Marc Turner (MLT)
Sam Rawlinson (SR)
Steve Taylor (ST)
Margaret Smith (MS) (Minutes)
Mr Thompson opened the meeting by welcoming Dr Fraser who was acting up
on the retiral of Dr Prowse.
It was agreed that the Seminar Room may be more conducive for future
Management Board meetings and Ms Smith was asked to explore this. Ms
Smith was also asked to ensure that members were asked to intimate their
apologies if they were not attending meetings.
B 11.77 1 MINUTES
A copy of the draft Minute version 3 of the meeting held on 19 th April 2011 was
tabled and several amendments were made. A copy of the amended Minute will
be circulated in due course.
B 11.78 2 ACTIONS ARISING
The actions arising had all been completed apart from the following:-
2.1 Access to SSTS and linking Q Pulse to Empower – Ref 2.1
Ms Emerson reported that a meeting had been scheduled for next week re
Communications Systems.
MS
MS
MS
JE
It was noted that the SSTS system had been introduced geographically and that
a tweak to the system was required to allow Donor Services staff access to the
system.
2.2 Risk Register – Ref Item 4.3
It was noted that some of the owners of risks had still to update the register.
All
With regard to the vacancies in NISD Mr Thompson asked both Clinical and
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Supply Chain Directors to see if they could identify a staff member to second to
NISD for a six month period.
2.3 Terms and Conditions – Ref Item 5.1
Professor Turner and Mr Bruce to identify key managers to work with Jacqui
Jones on the Terms and Conditions.
MLT, MB
MLT, MB
2.4 Strategy Refresh Day – Ref Item 4.2
I was noted that all the necessary paperwork would be sent out prior to the
Strategy Refresh Day on Monday, 6 th June 2011. It was planned that attendees
were not required to do any homework prior to the event.
B 11.57 3 NATIONAL DIRECTOR’S REPORT
The National Director’s report for May was circulated for information. The
following items were highlighted in the review:-
Scottish Clinical Transfusion Advisory Committee – 20 th April 2011
• Tour of Lauriston Facility. Mr Jeffrey planned to write a letter in
support of SNBTS’s proposal for a move to more suitable
premises
• SCTAC Workplan for 2011-12
• The programme for the Annual Meeting to be held on Friday, 30 th
September 2011
• BBT Quarterly report
NSS Executive Management Team – 26 th April 2011
• Measures to Reduce Workforce Costs in final stages of
development. Copies to be circulated to members
• Size of individual Boards.
• Fixed Term Contracts Policy - PIN out for consultation and R&D
are to work with Human Resources to provide feedback within
the given timescale. Contracts may be extended in exceptional
cases and it was agreed to discuss this further at the June
meeting
NSS Operating Committee – 26 th April 2011
• Cost Reduction Ideas
• Potential IM&T Cost Savings on IT Equipment
• Potential Cost Savings from Lease Cars Scheme including
changes to base cars
• More Customer Engagement including EMT members attending
Health Board meetings. A pilot is to be run, structured training
given and objectives clearly set out.
MS
RF, JE
4 FOR APPROVAL
B 11.80 4.1 Corporate Issues
Dr Quereshi presented the Corporate Issues Report which was tabled. The
following issues were discussed:-
• Two new risks had been added to the register
Risk id 2299 National Information Systems Directorate
Risk id 2277 Legacy Laboratory Host Interfaces (Prism/Olympus)
• Although Risk id 1743 ‘Donor Complaints’ was considered a low level risk
it was agreed that it should remain on the register meantime
• When discussing Risk id 1673 ‘Out of Hours Service’ it was agreed that
this should be discussed by the Clinical Governance and Safety
Committee
• The Organisational Change Portfolio Management Group had discussed
a reporting template at their last meeting and this will be developed by Dr
Qureshi and Steve Wallace
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• The red blood cell issues in Aberdeen show a variation in practice and
Professor Turner was asked to discuss this with the Clinical Directorate
• Clinical discards were discussed. Electronic monitoring and the 30
minute rule were seen as adversely impacting on the figures quoted
• Dr Qureshi agreed to check the April totals for platelet wastage
• The Supply Chain are mapping possible daily deliveries to Inverness. Mr
Thompson asked that as this was a priority project a timescale be
identified and that discussions with Paul Milne should take place within
the next quarter
• It was noted that the donor attendance had stabilised. It was recorded
however that SNBTS lose 40,000 donors from the active donor panel
each year
It was noted that the data provided did not give any measure of customer/order
fulfilment. In order to produce such data a definition of ‘standard’ supply would
be required. It was noted that Corporate Issues are due to employ the services
of an MSc student from Heriot-Watt University and that he/she could be asked to
develop this.
Dr Qureshi agreed to report to the next Management Board meeting the project
work identified by SNBTS which will be overseen by the Organisational Change
Portfolio Management Group.
MLT
SQ
MB
SQ
SQ
B 11.93 4.2 Accommodation at Ellen’s Glen Road
A paper written by Susan Rossborough was tabled and Dr Qureshi reported that
since the closure of PFC certain areas of the site had been reclassified as low
grade storage and that certain new developments had been accommodated
since then including Pancreatic Islet Cells, Penrose Inquiry and Home Therapy
Nurses. Accommodation to house the following is being requested:-
• Supply Chain to accommodate their Management Team
• Corporate Issues to give sufficient room to include the consultants
working on the National Centre
All Directors with staff in the PFC building had been written to asking them to
review their accommodation needs over the next five years. To date only a few
responses had been received and members were asked to do this as a matter of
urgency.
4.3 Seven Set
E-mails had been issued to all relevant staff requesting information for the Seven
Set meeting on Thursday, 2 nd June 2011. Dr Qureshi noted that she was
seeking more information from members on examples of working with Partners
and best practice.
All
All
B 11.81 4.4 Infection Control Annual Report
The SNBTS annual Infection Control Report to March 2011 was presented by
Mrs Millar. The report had not been reviewed by the Clinical Governance and
Safety Committee as the May meeting had been cancelled. The report will be
submitted to NSS and SGHD. Mrs Millar thanked Ann Paterson, Dr Lisa Jarvis
and Dr Cuthbertson for their input. The following issues were picked out of the
report for noting:-
• Infection Control policies were now on Q Pulse and it was hoped that
these would be available on GeNss shortly
• 740 staff had been trained in Hand Hygiene
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• 36 staff had completed the Cleanliness Champions programme
• Audits on Hand Hygiene had been carried out by Band 7 staff and the
Senior Nurse Infection Control and it was recorded that compliance was
good
• Finger dab tests showed how effective the alcohol gels are. A report on
the results achieved in the study of performing hand hygiene only
immediately prior to phlebotomy will need to be reviewed by NSS, SGHD
and HAI prior to a change in practice.
• SNBTS had contributed to an effective donor arm disinfection paper for
SACTTI and the contribution had been acknowledged
• The NSS National Uniform and Appearance Policy has been agreed in
Partnership and is currently out for consultation
Mr Thompson thanked the Infection Control Committee for a good report and
asked that the training figures be incorporated in the Seven Set data.
B 11.92 4.5 SNBTS HAI Reporting Template
The report had been previously reviewed by the Infection Control Committee but
not the Clinical Governance and Safety Committee. The report is reviewed by
NSS Board and SGHD. The Hand Hygiene programme was covered earlier in
the meeting and the discussion focussed on the Cleaning Template. The results
of the audit carried out at the Edinburgh Royal Infirmary were discussed and
details are to be included in the report to NSS.
SQ
JM
It was noted that the new framework for cleaning reports would include estate
issues, an action plan on remedial work and timescales will be included.
5 FOR CONSIDERATION
B 11.82 5.1 Local Delivery Plan 2011-12
It was noted that the NSS Local Delivery Plan for 2010-11 had been wrongly
circulated. The up to date report will be issued in due course.
5.2 Business Plan
The SNBTS Business Plan was not available and this item was deferred.
5.3 Staff Governance – Team Talk
The Chief Executive is promoting face to face staff briefings starting in May. A
copy of the user guide for leaders and managers was tabled along with a copy of
the discussion notes prepared by NSS. Divisions and Directorates are invited to
add their own local issues to ensure the briefings are a useful tool. Feedback is
to be captured and sent to Mrs Kidd. It was noted that the briefings are to be
held within two weeks of the issue of the NSS notes. Team talks will form part of
the Seven Set performance targets and will form part of managers’ objectives.
SQ
SQ
SQ
It was noted that it was planned to have another Big Conversation to be chaired
by Mr Ian Crichton. It was reported that Mr Crichton would visit several SNBTS
sites to discuss issues with staff who may not have access to a PC.
B 11.94 5.4 Regulatory Compliance Report
The Regulatory Compliance Report which was tabled had not yet been reviewed
by the Clinical Governance and Safety Committee as the date scheduled for the
May meeting had been cancelled. Dr Cuthbertson reported on the following
issues:-
• The Factor VIII levels of FFP recorded in March were below specification.
It was noted that the assay will be reviewed
• No MHRA inspections had taken place during the quarter January to
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B 11.88 5.5 E-Progesa
B 11.89
B 11.90
March. However a recent corneal inspection had gone very well and
only 5 others had been reported. It is expected that this will be closed
out this week and that SNBTS will get a licence. The Aberdeen centre is
due to be inspected on the 21 st and 22 nd June
• CPA had inspected Dundee during March and this had been closed out
• The audit programme was progressing well
• No category red incidents had been reported in the quarter
• Saber Reports were discussed.
The report was accepted without need of correction.
Reports submitted by Angela Lawrie covering the period 14 th March to 21 st April
2011 were circulated. It was anticipated the e-Progesa would go live during the
weekend of 1 st July. Twelve critical defects were reported but these were being
attended to and three critical performance issues will be addressed during
Performance Testing. Additional resource had been allocated to Performance
Testing and training had been completed.
The governance board chaired by Moira Carter had asked for weekly updates
and a two week contingency period had been built into the planning schedule.
The collection of apheresis platelets over the Go Live weekend was discussed
and a communications package had been included in the action plan.
B 11.83 5.6 Infection Control Committee
A copy of the Minute of the meeting held on 17 th January 2011 had been
circulated for information.
Mrs Millar gave a verbal update on the meeting held on 27 th April and included
the following issues:-
• Annual Report for 2010-11 previously discussed in the meeting
• The plan to add Infection Control Policies to GeNSS
• A meeting is to be scheduled with Denise Booth-Alexander to discuss the
NSS Waste Policy. The Model Policy has now been issued and it is
hoped that NSS could adopt this
• The number of needle stick injuries had increased and this may be due to
the new packs
• Some of the drivers had lodged complaints regarding the National
Uniform
B 11.91 5.7 Human Resources
B 11.84
B 11.85
B 11.86
The following papers had been circulated:-
• SNBTS Promoting Attendance report
• Balance Scorecard
• SWISS Sickness Absence for March
• NSS Joint Outcomes Report
Ms Emerson reported that the SNBTS absence figure for March was 5.24%
compared with 3.37% the previous year. Ms Emerson had asked the Service
Centre for a breakdown of the figures so that their accuracy could be checked
before these were closed off.
The Sickness Absence Report taken from SWISS was discussed and it was
agreed that the categories may not reflect the true position in SNBTS and it was
felt that some areas had not been included. The primary classifications on
SWISS are to be reviewed.
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Absence rates had risen since April 2010 and it was suggested that SNBTS data
should be compared with one of the Health Boards.
It was noted from the Joint Outcomes report that the informal cases for SNBTS
had dropped to 50. This had been due to a better understanding of the definition
and some cases had not been left open for too long.
Turnover of staff was recorded just under 5%. Thirteen vacancies which were in
the recruitment process had been recorded but there was a considerable
number of vacancies which had not been included. Mr Thompson agreed to
speak with Ms Emerson outwith the meeting regarding the appointment of
locums.
KT
B 11.87 6 CALENDAR
A copy of the Calendar of Issues for 2011 was circulated for information. It was
agreed that the following items should be added for the June meeting:-
• Business Plan
• Modernisation of Manufacturing
7 ANY OTHER BUSINESS
7.1 E-KSF
Dr Fraser reported that SNBTS had achieved 79% of reviews completed on e-
KSF. The NSS total was 90%.
Mr Thompson thanked Dr Fraser and all the members for their efforts in
achieving the results.
7.2 Incident Control Committee
Professor Turner gave a verbal update on the CJD Incidents Panel meeting.
7.3 Tayside Apheresis Service
Mr Thompson reported on a meeting he, Dr Green and Mrs Millar had had with
the Tayside Medical Director and Consultant Haematologist. Agreement had
been reached regarding the future of stem cells and this would be transacted as
soon as possible. The clinical apheresis service in Dundee is deemed to be
unsustainable and options will require to be evaluated. Dr Rachel Green is the
lead on this.
8 DATE OF NEXT MEETING
Members were asked to note that the scheduled meeting had been arranged for
Wednesday, 15 th June 2011 and that papers required to be submitted by Friday,
10 th June 2011.
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