Report to: Public Trust Board Date of Meeting: 8 April Agenda item: 12.1

Transcription

1 Report to: Public Trust Board Date of Meeting: 8 April 2009 Agenda item: 12.1 Title of Report: Status: Board Sponsor: Author: Appendices Clinical Governance Report Standing Item Michael Earp, Non-Executive Director Francesca Thompson, Director of Nursing None 1. Purpose of Report (Including link to objectives) To meet the Assurance function of the Clinical Governance Committee 2. Summary of Key Issues for Discussion 2.1 Standards for Better Health year end declaration 2.2 Policy review 2.6 Never events 3. Recommendations (Note, Approve, Discuss etc) Read and note the contents of the report 4. Standards for Better Health (which apply) All 5. Legal / Regulatory Implications (NHSLA / ALE etc) NHSLA (level 2): All 6. Risk (Threats or opportunities link to risk on register etc) Failure to achieve assurance on compliance with the Healthcare Commission standards Agenda Item: 12.1 Page 1 of 5

2 7. Resources Implications (Financial / staffing) None identified 8. Equality and Diversity No specific aspects of equality and diversity addressed within this report 9. Communication Openness and transparency is central to clinical governance systems and processes within the RUH. 10. References to previous reports Routine monthly report to the Trust Board 11. Freedom of Information Public Agenda Item: 12.1 Page 2 of 5

3 Clinical Governance Report 1 Introduction 1.1 This report outlines the key clinical governance issues identified by the Clinical Governance Committee in March Key issues 2.1 Standards for Better Health, Year End Declaration. An overview of the documents received as evidence of compliance against the relevant Standards for Better Health was presented to the committee. Safeguarding Children (Standard C2) was highlighted as an area that may come under further scrutiny and as a response to the most recent Heath Care Commission (HCC) review on Children s Services the Trust may receive an unannounced visit. Some gaps had been identified in relation to insufficient assurance of training records, monitoring performance, safeguarding practices and levels of reporting to the Trust Board. The RUH is still awaiting a report from the Healthcare Commission, following their visit regarding the Hygiene Code. This is predominantly linked to the standard on Decontamination (C4c). The Director of Strategic Planning and the Head of IM&T have confirmed their decision to declare compliance on the Health Records Standard (C9). The Clinical Governance Committees asks the Non Clinical Risk Committee to formally address the theme of mandatory training records. It was noted that there are over HCC 400 comparative indicators and only these three have been highlighted as a raising some concern. Everything else was found to be above or in compliance with the Standards. It was reported that there is far more confidence regarding the Health Promotion Standard (C23), following the uncertainty of last year. The Clinical Governance Committee felt able to assure the Board on compliance with the Standards. Agenda Item: 12.1 Page 3 of 5

4 2.2 Policy review In view of the very significant number of out of date relevant policies the Clinical Governance Committee has agreed to extend their review dates as an interim measure to allow time for more considered review. It was of particular concern that out of date policies remain on the Trust intranet and internet, where they are accessed by external bodies such as the Healthcare Commission and the National Health Service Litigation Authority (NHSLA). These out of date documents on our internet undermine our assurance of effective Governance. 2.3 Review of the Ophthalmic Serious Untoward Incident The internal investigation by the Medical Physics Team has discovered that the industry standard microscope light-filter settings (and including those in the RUH s specific equipment manuals) were incorrect. Once further comment has been received from the Moorfield s Eye hospital expert on these findings, it is proposed that the information will be progressed through the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA has been informed, but no feedback has been received. 2.4 Risk Management database replacement A contract has been signed with GAEL Quality for their Document Management System. Discussions are in hand to establish whether GAEL can develop a significantly improved Risk Management database and Risk Register but as this is unlikely to be available by the end of 2009, contingencies are under review. 2.5 MHRA Blood Bank Inspection Report Following the follow up visit on the 10 March 2009, the RUH was declared compliant with the Medicines and Healthcare products Regulatory Agency (MHRA) Standards. 2.6 Serious Untoward Incidents combined Action plan The Committee agreed to the removal of two obstetric Serious Untoward Incidents (SUIs), following completion of their action plans. The Committee approved the two root cause analysis investigation reports into two recent SUIs and the subsequent recommendations. These actions will be added to the combined action plan. Agenda Item: 12.1 Page 4 of 5

5 The Committee were apprised of the publication of the National Patient Safety Agency Never Events document, which identifies the proposed withdrawal of payment by PCT s if a Never Event SUI occurs. The RUH would identify such events through its routine Incident Reporting process and in the combined SUI action plan. 2.7 Changes to the Complaint Handling process The recent Department of health guidance is aimed at a more flexible approach, leading to more face-to-face meetings with those who have made a complaint. In addition, complaints will be referred to the Ombudsman if they are not resolved locally. The concern regarding immediate compensation payouts by Trusts was also raised. 2.8 The MRSA policy The Committee ratified this policy. 2.9 Trust Wide Risk Register Review The Committee formally closed completed or redundant risks as identified by the Risk and Clinical Effectiveness (RACE) Panel NHSLA risk Management Standards for Acute Trusts Assessment at Level 2 demonstrates the effective implementation of policies presented at the Level 1 Assessment. Work to identify the evidence and build a portfolio for assessment at Level 2 is underway and will be reviewed by the Assessor in October, prior to formal assessment in week commencing 22 February Agenda Item: 12.1 Page 5 of 5