agenda-a3 - Northern Devon Healthcare NHS Trust NDHT

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS TrustReport to Trust BoardDate Tuesday, 07 July 2009Agenda Number A3Agenda Item Clinical Governance Committee MinutesSponsor Alison Diamond, Associate Medical Director / Clinical Governance LeadPrepared by Mandy Kilby, Clinical Governance ManagerPresented by Mandy Kilby, Clinical Governance Manager1 Purpose and key issuesEXECUTIVE SUMMARYTo present draft Clinical Governance Committee minutes for the meeting held on 9 June2009, numbers 123/09 to 144/09.Key issues include: The development of a Clinical Governance Framework for Minor Injury Units whichincludes training and development, links with GPs, radiology and A&E; the work isbeing fed back to the MIU Workstream meetings; The development of Ophthalmic Clinical Nurse Specialist A&E Services; and The discussion of the national NCEPOD Report: Trauma – who cares? and that thethree recommendations with which the Trust was non-compliant should have actions,be risk assessed and placed on the Corporate Risk Register.2 Controls and assurancesThe minutes of the meeting are considered by the Clinical Governance Committee foraccuracy. Following discussion, amendments may be recorded as appropriate. Theminutes are then formally approved by the Committee.An accurate record of the proceedings of the meeting is required in order to ensure thatthe Board meets its duties in accordance with the Trust's Scheme of Delegation, StandingOrders and Standing Financial Instructions. Copies of the Clinical Governance Committeeminutes are presented to the Audit and Assurance Committee and to the Trust Board tonote.The Trust's clinical governance management arrangements have been developed tomeet the requirements of the NHS Litigation Authority's Risk Management Standards forAcute Trusts and of the Healthcare Commission's Standards for Better Health. They areperformance monitored by the NHS South West Strategic Health Authority through theimplementation of the Clinical Governance Development Plan.3 Legal ImplicationsThe legal implications have been considered and there are none.Clinical Governance Support Unit Page 1 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS Trust4 Equality and Diversity ImplicationsThe Trust aims to design and implement services, policies and measures that meet thediverse needs of our service, population and workforce, ensuring that none are placed ata disadvantage over others. No adverse or positive impacts have been identified fromthis report.5 Patient, Public and Staff InvolvementThe Trust's business planning process incorporates patient and public involvement.Robust and effective financial control and risk management systems ensure that theTrust's services can be developed and delivered to meet the needs of patients in themedium term.6 Cost implicationsThere are no cost implications.7 Potential risk to the organisationIf the minutes are not approved by the Clinical Governance Committee, the Trust will beat medium risk of not acting in accordance with the organisation’s Standing Orders,Standing Financial Instructions and Scheme of Delegation. Risk score 9 (Consequence= 3 x Likelihood = 3).8 Board promptsHas the Board had an opportunity to raise questions or concerns with the Chair ofthe Committee?Is the Board confident that there are effective systems for identifying potentialissues early and for keeping the Board informed?9 RecommendationsThe Board is asked to NOTE the minutes of the Clinical Governance Committeemeeting held on 9 June 2009.10 Strategic ObjectivesThe Trust’s Strategic Objectives are reviewed annually and approved by the Board.X Patient & staff safety High quality servicesX Effective & efficient services Highly skilled & motivated workforceX Positive patient experience Modern facilitiesCare delivered in most appropriate settingEffective partnerships for better public healthPersonalised care X Robust & sustainable futureClinical Governance Support Unit Page 2 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS Trust11 Principal RisksThe Principal Risks have been identified through the Trust’s risk managementprocesses. They are updated as and when required.Financial planning & managementClinical records managementStrategic & business planning X Leadership & managementWorkforce numbersUnsafe behaviourWorkforce skillsExternal demandsX Procedural management Partnership arrangementsEquipment & facilities arrangements14 Standards for Better HealthThe core Standards for Better Health have been developed by the HealthcareCommission. Compliance with the Standards throughout the year forms a part of theTrust’s Annual Health Check.X C1a Incident Reporting X C7c Clinical Governance X C14cXXC1b Safety Alerts X C7eC2 Child Protection C8aC3NICE – InterventionalproceduresC8bEquality & DiversityWhistle blowingPersonal DevelopmentProgrammesXC15aC4a Infection Control C9 Records Management C18C4b Medical Devices C10a Employment Checks C19C4c Decontamination C10bC4dMedicineManagementC4e Waste Management C11bC5aC5bC5cNICE – TechnologyappraisalsClinical Supervision& LeadershipClinical ProfessionalDevelopmentXProfessional Codes ofConductC16C17C20aC11a Recruitment C20bC11cC12Mandatory TrainingProfessionalDevelopmentResearch &DevelopmentC21C22aC22bC13a Dignity & Respect C22cX C5d Clinical Audit X C13b Consent to treatment C23C6C7aHealthcare bodies cooperatingtogetherCorporateGovernanceXXC13cC14aC7b Finance & Probity X C14bUse of ConfidentialInformationComplaints – InformationComplaints – NondiscriminationC24Complaints –ServiceimprovementsPatient FoodStandardsPatientInformationPatient & PublicInvolvementAccess toServices –Equality & ChoiceAccess toServices –Emergency careSecurity andHealth & SafetyPatient Privacy &ConfidentialityHospitalCleanlinessPublic Health –HealthinequalitiesPublic Health – Dof PH reportPublic Health -Working withpartnersPublic Health –Health promotionMajor IncidentPlanningClinical Governance Support Unit Page 3 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS TrustDRAFTMinutes of a meeting of the Clinical Governance Committee held in the Boardroom,Chichester House, North Devon District Hospital, on Tuesday, 9 June 2009PRESENT: Mandy Kilby Clinical Governance Manager (Chair)Mike Ambridge Medical Equipment ManagerJuliet CrossHead of Corporate AffairsSam JonesNon-Executive DirectorPauline Lockwood Community Hospitals & Nursing RepresentativeCarolyn Mills Director of Nursing / Joint Director of InfectionPrevention & Control (Item 137/09)Tracey Polak Assistant Director of Public Health, Devon PCTJim RhymerChair, Clinical Audit & Effectiveness GroupNeil Schofield General Manager, Diagnostics DirectorateINATTENDANCE: Sue Oliver Senior Nurse, Bideford Community HospitalNichola Addicott CNS Ophthalmology (Item 125/09)Jo Tripp CNS Ophthalmology (Item 125/09)Andy CoxLearning & Development (representing Lin Sanders)Sue Whitworth Senior Midwife/Risk Lead (representing Julia Drury)ACTION123/09 CHAIR'S REMARKSThe Chair welcomed everyone to the meeting.124/09 APOLOGIESApologies were received from Mark Cartmell, Michelle Cobby, Paul Cooper, AnnetteCrew, Alison Diamond, Richard Lee, Mark Meller, Carolyn Mills, Julie Poyner, Lin Sanders125/09 CLINICAL HOTSPOTClinical Governance Framework for the Minor Injury UnitsSue Oliver presented a paper outlining governance and working arrangements for theMinor Injuries Units. These include the developing role and competency framework forMIU nurse practitioners, the development and ratification of Patient Group Directives(PGDs) and guidelines for common conditions, the quarterly continuing professionaldevelopment (CPD) education programme, MIU Tarkanet pages, and annual audit plan.The work of the MIU group has raised issues around working with GPs, their links withA&E and opportunities for CPD. Webpacs and the helpline which has been establishedhave had a very positive impact for MIUs. Trauma cases are often discussed with A&Estaff. It was NOTED that MIU staff could also contact Radiology for advice – there is adaily liaison radiologist available. This will be fed back to the next MIU Workstreammeeting.Ophthalmic CNS A&E ServicesNichola Addicott and Jo Tripp gave a presentation on the changing and enhanced role ofOphthalmic Clinical Nurse Specialists (CNS). Clinical competencies have been developedwith RD&E and both are fully trained prescribers. There is currently a shortfall in theSOClinical Governance Support Unit Page 4 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS Trustnumber of doctors available to carry out A&E services, and an increase in the number ofpatients. There is high demand for clinic slots.After some discussion the Committee: NOTED a proposal for the CNSs and a nurse practitioner (working under protocols) tocarry out one session a week seeing A&E patients (new, follow-ups and GP referrals).This will be timetabled into the clinic rota; NOTED the nurse practitioner will receive training to a similar standard as the CNSs inorder to handle A&E ophthalmic visits; NOTED a proposal to introduce one clinic a month run by the CNS for facial spasmpatients receiving botox treatment which would represent a cost and efficiency savingand free up consultant clinic slots; AGREED that as this procedure is new to the Trust appropriate protocols will need tobe developed and ratified; AGREED that where facial spasm patients currently seen at RD&E are transferred tothe NDDH clinic, the Trust will need to ensure that funding follows the patient; NOTED the PCT is currently tightening up on low priority procedures and theprescribing of botox and that checks should be made with the PCT about whether theservice has been commissioned; AGREED the procedure and commissioning concerns should be discussed with theDirectorate General Manager for Surgery; NOTED a proposal for CNSs to carry out an agreed list of minor operations for basicprocedures; AGREED the protocol for minor procedures in Meibomian Cyst Clinics to beundertaken by the CNS should be reviewed with the Consultant Ophthalmologist andconsulted on in terms of reducing the age limit from 16 – 14; AGREED a competency for electrolysis for in-growing eyelashes should be developedin conjunction with Learning & Development;NOTED the proposal that consenting for cataract surgeries is to be carried out by theCNSs and nurse practitioner, and AGREED that compliance with the Consent Policyshould be checked and other organisations consulted on their consent processes inophthalmology. The proposal to be brought back to the Clinical GovernanceCommittee with this further information; NOTED that ophthalmic competencies could also be used by MIU staff. TheOphthalmic CNSs agreed to attend MIU clinics and train staff, and take the ophthalmiccompetencies to the MIU Workstream; andAGREED that the New Interventional Procedures Policy should be followed for allprocedures where appropriate.NAJTJT/HBTP/HBJTNA/CGNA/LSNANA126/09 MINUTESThe Minutes of the meeting held on Tuesday, 12 May 2009, numbers 101/09 to 122/09,were considered and APPROVED, subject to the following amendments:105/09: Infusion device safety returns – Noted there was an Asset Register for all equipment valued over £5,000 … held inthe Finance Department and all equipment valued over £25 held in EBME;Clinical Governance Support Unit Page 5 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS Trust Delete second bullet point: NOTED that there was no complete library of medicalequipment … NOTED that … the complete inventory could be shared so staff were aware of whatequipment was held by the Trust and available for use105/09: Strategic Workforce Development Group – ... and agreed that the SWDG would not remain a specialist advisory group reportingto the CGC, but instead would report to the Finance and Performance Group.127/09 MATTERS ARISING103/09: Mid Staffordshire Report –The Committee NOTED that the Associate Medical Director and Clinical GovernanceManager had been tasked with putting together an overview of recommendations whichwould be shared at the Executive Directors Group and Clinical Governance Committee.105/09: Pathology Filing in Patient Notes –The Committee NOTED that the matter had been discussed with the Patient Safety Leadand was on the agenda for discussion at the next meeting of the Patient DocumentationGroup.AD/MK105/09: Infusion Device Safety Returns –The Medical Equipment Manager reported that the risk had been assessed and actionsidentified for inclusion in the corporate risk register. All MS16A devices would becomeretired assets after an agreed date.105/09: NICE Progress Report –The Chair of the Clinical Audit & Effectiveness Group (CAEG) reported that the Childrenand Young People Guidance had not yet been risk assessed. AGREED that this shouldbe reported at the next meeting.AEC/CM105/09: Clinical Audit & Effectiveness Annual Programmes –The Committee NOTED that the dashboard-style overview was currently being developedand that the Patient Safety Lead had been contacted concerning representation on theCAEG.111/09: Maternity Services Patient Safety Forum –After some discussion the Committee AGREED that the Maternity Dashboard should bereported quarterly to Trust Board in order to provide assurance about the safety andquality of maternity services.116/09: Volunteer Policy –The Clinical Governance Manager reported that the amendments to the Volunteer Policyhad been made and the Policy would now be presented to Trust Board for ratification.118/09: Mortality Figures –The Clinical Governance Manager confirmed that mortality data would be discussed atmonthly Clinical Leads meetings and the Clinical Governance Committee would receiveactions arising from the reports. The first report will be presented to the next meeting.128/09 CLINICAL GOVERNANCE STRATEGYThere was nothing to report.129/09 CLINICAL GOVERNANCE DEVELOPMENT PLAN UPDATEJFC/JDADADThese are brought to the Committee quarterly and would be reported at the meeting on 11August 2009.JPClinical Governance Support Unit Page 6 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS Trust130/09 INTERVENTIONAL PROCEDURES REQUESTSLipo filling of breast:The Clinical Governance Manager reported to the Committee on this procedure which hadbeen carried out on a number of breast reconstruction patients who had been speciallyconsented. The specialist surgeon who would carry out the procedures was from anotherTrust and had an honorary contract. The Medical Director was satisfied that theappropriate governance arrangements were in place and, in line with the NewInterventional Procedures Policy, had agreed that the procedure could be undertaken withthe issues being discussed subsequently at Clinical Governance Committee.After some discussion the Committee:NOTED concerns raised by the Chair of CAEG about potential issues in follow-up,both radiographic and clinical, and the potential risk to subsequent diagnosis;NOTED concerns that the service may not be commissioned and the potential impacton the rest of the service; andAGREED that the Clinical Governance Manager should forward further details byemail to members of the Committee, and contact the Medical Director and the ClinicalLead for Surgery to raise these concerns.131/09 SPECIALIST ADVISORY GROUPS: MINUTES OF MEETINGSMKInfection Prevention & Control Committee (IPCC), 28/04/09:The Clinical Governance Manager presented the minutes of the IPCC held on 28 April2009. After some discussion the Committee:NOTED the update on the global pandemic alert, daily meetings of the planning groupand the progress being made with preparations, and the raised alert level;NOTED the IPCC is monitoring MRSA screening figures as part of its dashboard dataand that work was ongoing to ensure that patients with multiple admissions are onlycounted once; andNOTED the minutes.Maternity Services Patient Safety Forum (MSPSF), 21/05/09:The Senior Midwife/Risk Lead presented the minutes of the MSPS held on 21 May 2009.After some discussion the Committee:NOTED that a guideline was being drawn up to address follow-up and referral issuesraised through incident IRF 60693, shoulder dystocia;NOTED the ongoing discussions concerning sessions for caesarean sections;NOTED there were currently two investigations looking at scanning matters and thatthe round table reviews had been held last week;NOTED that the Medical Director and Clinical Lead for Obstetrics had met theparents to go through findings of a recent SUI;AGREED that the recommendations and action plan arising from the SCBU SUIshould be risk assessed and placed on the corporate risk register for monitoring;HB/JPhNOTED the neonatal early warning score was being used on high risk babies, e.g.where there had been problems during pregnancy, drug / alcohol issues, or the babywas born unwell;NOTED that there were concerns about newborn examinations and that discussionswith the PCT were ongoing;NOTED that the Productive Ward Day had taken place on Bassett Ward and wasplanned on Labour Ward in June;NOTED the introduction of new maternity notes with effect from next week and thattraining of midwifery staff had been completed;Clinical Governance Support Unit Page 7 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS TrustNOTED the concerns about midwifery staff establishment; andNOTED the minutes.132/09 SPECIALIST ADVISORY GROUP TERMS OF REFERENCEClinical Audit & Effectiveness Group (CAEG):The Chair of CAEG presented the Draft Terms of Reference 2009-10. After somediscussion the Committee:NOTED the ongoing problems with attendance and renewed focus on making themeeting more operationally focussed;AGREED that attendance at meetings should be monitored by the Chair of the CAEGand the draft terms of reference should be amended to reflect this; andAPPROVED the draft terms of reference.DL133/09 SPECIALIST ADVISORY GROUP REPORTSClinical Audit & Effectiveness Group (CAEG):The Chair of CAEG presented the NICE Progress Report 01/01/06 – 07/05/09 and AnnualAudit Programmes 2009-10. After some discussion the Committee:NOTED the NICE Progress Report and the continuing discussions with cliniciansaround managing the process and providing assurance;NOTED concerns raised by the Chair of CAEG that clinical audit may not be the onlytool for providing assurance;NOTED that some NICE Guidance may have implications for equipment purchasing,and AGREED that the Medical Equipment Manager should look into this and reportback to the next meeting;AGREED that the Chair of CAEG should contact the Director of Development withregard to re-allocation of the Public Health audit projects; and NOTED the NICE Progress Report and Annual Audit Programmes 2009-10.MAJR134/09 RISK MANAGEMENT COMMITTEEThe Head of Corporate Affairs presented the draft minutes of the Risk ManagementCommittee held on 21 May 2009. After discussion the Committee:NOTED the Assistant Director of Public Health’s concerns about the delays in reassessingthe risk score for Risk ID 911 – Risk of failure to have adequate pandemicflu plan. The HPA level is currently at 5 and moving to a 6;AGREED that the Head of Corporate Affairs should expedite the matter with the Riskand Incident Manager;NOTED that Risk ID 732 – Risk that staff are not trained in basic life support/resuscitation had not been accepted and that the Risk Management Committee hadrequested additional actions to be put in place;NOTED there were no new 15+ risks added to the corporate risk register for May2009; andNOTED the minutes.135/09 STANDARDS FOR BETTER HEALTHThere was nothing to report.136/09 NHS LITIGATION AUTHORITYClinical Governance Support Unit Page 8 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS TrustThe Committee NOTED that an informal assessment for CNST Maternity Level 2 wouldtake place on Thursday 11 June 2009.137/09 POLICIESMental Capacity/Deprivation of Liberty Safeguards Policy:The Director of Nursing presented the policy to the Committee for comment. It haspreviously been to the Safeguarding Adults Group and reviewed in the context of theDevon-wide Mental Capacity Implementation Group. It particularly addresses the issue ofsignposting with clear pathways and access to appropriately trained staff through thePathfinder Team. Awareness will be raised through delivery of training via an e-learningpackage for basic awareness and further specialist and higher level training forappropriate staff. The Committee NOTED the Mental Capacity/Deprivation of LibertySafeguards Policy.138/09 NATIONAL REPORTSNCEPOD Report: Trauma – who cares? (November 2007):The Clinical Governance Manager presented the Trust response to the NCEPOD Reportwhich had been put together by Dr Fionn Bellis, Consultant in Emergency Medicine. Aftersome discussion the Committee: NOTED the 3 recommendations with which the Trust is currently non-compliant -subscription to UK TARN (UK Trauma Audit Research Network); development ofclear alerting guidelines agreed on a regional basis through the Regional TraumaNetwork; and formation of a Trust Trauma Management Group; RECOGNISED the importance of the relevant clinical team having ownership of suchdocuments and the positive outcomes; AGREED that the recommendations and actions should be risk assessed and placedon the corporate risk register; andAEC/MR NOTED the report.139/09 ANY OTHER BUSINESSThere was no other business.140/09 NEXT MEETINGThe next meeting of the Clinical Governance Committee would take place on Tuesday 14July 2009, from 10.00 to 12.00 noon, in the Boardroom, North Devon District Hospital.141/09 CONFIDENTIAL SECTIONItems for discussion in the confidential session could include confidential clinicalgovernance or individual patient issues.142/09 EXCLUSIONThe meeting RESOLVED that, due to the confidential nature of the final business to betransacted, the meeting moved to a confidential session.144/09 CLOSE OF MEETINGClinical Governance Support Unit Page 9 of 10

Clinical Governance Committee MinutesTrust Board, 7 July 2009Northern Devon Healthcare NHS TrustThere being no other business, the meeting closed at 11.35.Clinical Governance Support Unit Page 10 of 10