Healthcare Quality Assurance and Improvement Committee - Overview of Events in Scotland

Transcription

1 Healthcare Quality Assurance and Improvement Committee Annual Report 2014/15 1. Introduction The Healthcare Quality Assurance and Improvement Committee is accountable to the Lanarkshire NHS Board and is responsible for the development of a strategic approach to strengthening healthcare quality assurance and improvement across the organisation, and ensuring that quality standards are being set, met and continuously improved in appropriate areas of clinical activity. 2. Committee Chair Members and Attendees Committee Chair: Mr M. Fuller, Non-Executive Director Committee Members: Mr T. Steele, Non-Executive Director Dr A. Osborne, Non-Executive Director Miss M. Morris, Non-Executive Director Cllr J. Burns, Non-Executive Director Dr A. Docherty, Chair, Area Clinical Forum Attendees: Mrs N. Mahal, NHS Board Chair Mr I. Ross, Chief Executive (to 31 st December 2014) Mr C. Campbell, Chief Executive (from 5 th January 2015) Dr I. Wallace, Medical Director Professor R. Lyness, Director for Nurses, Midwives and the Allied Health Professionals (to 1 st February 2015) Mrs I. Barkby, Director for Nurses, Midwives and the Allied Health Professionals (from 2 nd February 2015) Dr H. S. Kohli, Director of Public Health and Health Policy Mr K. A. Small, Director of Human Resources Dr J. Burns, Divisional Medical Director, Acute Services Dr C. Mackintosh, Associate Medical Director, Primary Care Mrs P. Milliken, Head of Clinical Governance and Risk Management (to 28 th February 2015) Mrs C. McGhee, Corporate Risk Manager Ms J Murkin, Acting Head of Clinical Governance and Risk management (from 1 st March 2015) and Head of Patient Safety and Improvement Mrs M. Cranmer, Staff Side Representative Mr A. Crawford, Head of Clinical Governance, NHS Greater Glasgow and Clyde Professor K. Rooney, Professor of Care Improvement, University of the West of Scotland Mr N. J. Agnew, Board Secretary

2 3. Meetings During 2014/15 During 2014/15 the Healthcare Quality Assurance and Improvement Committee met on six occasions, in line with its terms of reference. Meetings were held on: - 10 th April th June th August th October th December th February Issues Considered by the Committee During the Year During the year the Committee considered items for healthcare quality assurance and improvement, and received ongoing assurance in line with its schedule of reporting, the Annual Report for 2013/14, and the Governance Statement. Activity to strengthen healthcare quality assurance and improvement arrangements during 2014/15, included: 4.1 Healthcare Improvement Scotland (HIS) Hospital Standardised Mortality Ratio (HSMR) Rapid Review In the latter part of 2013/14, the Committee considered, for the first time, the Healthcare Improvement Scotland Rapid Review Report and a Programme Plan to address the review recommendations. At each of its meetings during 2014/15, the Committee exercised oversight of progress in the delivery of the Programme Plan, latterly focussing on the clinical elements of the Programme Plan. Members welcomed the focus and the pace at which the Programme Plan was taken forward, and also welcomed the confirmation of the many positive changes that had ensued. 4.2 The Francis Inquiry Report Having considered and endorsed a stocktake for Lanarkshire against the Inquiry Report recommendations, members welcomed and endorsed an assessment report demonstrating substantial progress in the implementation of the recommendations relevant to Lanarkshire. 4.3 Vale of Leven Hospital Inquiry Report The Committee considered and endorsed a report on a gap analysis undertaken in relation to the Inquiry findings and recommendations, and endorsed an Action Plan to address the recommendations relevant to Lanarkshire. Members welcomed the developments in Healthcare Associated Infection Prevention and Control, many of which were in place prior to the publication of the Inquiry Report, but welcomed the strengthened emphasis which the Inquiry Report brought to the endeavour to further improve prevention and control arrangements in Lanarkshire. The Committee will continue to receive progress reports on delivery of the Action Plan, until Members are assured about its delivery in full. 4.4 Patient Safety The Committee considered and endorsed a Patient Safety Strategic Prioritised Plan, and received regular reports during the year on its delivery and the

3 progress of the Patient Safety Collaborative. Members were particularly pleased at the substantial support for the Patient Safety Collaborative, and welcomed the Ministerial recognition at the Board s Annual Review of the progress made on patient safety in Lanarkshire. 4.5 Independent Review of Neonatal Unit Members considered the Independent Review Report on the Neonatal Unit, and endorsed an Action Plan to address the review recommendations. Members welcomed the confirmation which the independent review provided of standards within the Neonatal Unit, and the commitment and enthusiasm shown in taking forward the review recommendations. Members received progress reports on delivery of the Action Plan during the year, and will continue to receive progress reports until they are assured about its delivery in full. 4.6 Healthcare Environment Inspectorate: Healthcare Associated Infection The Committee considered HEI: HAI Inspection Reports and Action Plans during the year. Members gave particular consideration to the HEI Report on the inspection undertaken at Hairmyres Hospital in September 2014, which identified concerns in relation to environmental cleanliness and the cleanliness of near-patient equipment. Committee members also endorsed a comprehensive Action Plan to address the Inspection findings and recommendations, and welcomed the urgent endeavour to address the findings, and to put sustainable measures in place to avoid a recurrence. Members will continue to receive periodic progress reports on the implementation of the Action Plan, until they are assured about its delivery, in full. 4.7 Healthcare Improvement Scotland Review of the Arrangements for the Management of Adverse Events Members considered the HIS Report on the Review of arrangements for the management of adverse events, and welcomed the confirmation of the actions taken in Lanarkshire to ensure that local arrangements are consistent with the National requirements. Throughout the year, members considered adverse events data review reports, with a particular focus on action and learning across the organisation. 4.8 Primary Care Out of Hours Services The Committee received progress reports on the review of Primary Care Out of Hours Services, and endorsed the review conclusion and recommendations, prior to the Board s approval to consult on the review outcomes on options for the future delivery of safe, sustainable Primary Care Out of Hours Services. 4.9 Healthcare Quality Assurance and Improvement Strategy The Committee considered and approved a Healthcare Quality Assurance and Improvement Strategy and also received progress reports on its implementation Person-Centred Health and Care Programme Members considered and endorsed a Person-Centred Health and Care Prioritised Plan, and welcomed the focus which it provided for the continuing endeavour to deliver the Person-Centred Health and Care Programme in Lanarkshire. Members also welcomed periodic reports during the year on the delivery of the Programme Care Assurance and Accreditation Systems and Nursing Leadership and Governance Committee members welcomed the substantial endeavour on Care

4 Assurance and Accreditation Systems, with particular regard to the strengthened focus on nursing leadership and governance. At its final meeting in 2014/15, the Committee considered and welcomed a report and a presentation which demonstrated implementation across a range of areas and, encouragingly, evidenced substantial enthusiasm for the initiative Corporate Clinical Policies Members welcomed reports during the year which confirmed compliance with the requirement for timely review and, as appropriate, updating of Corporate Clinical Policies Food, Fluid and Nutrition Standards Members considered and welcomed a report on the application of the national Food, Fluid and Nutrition Standards in Lanarkshire, in the areas of: policy and strategy; assessment screening and care planning; planning and delivery of food in hospital settings; provision of food, fluid and nutrition to patients in hospital; patient information and communications; and education and training for staff. Members were particularly encouraged by the recognition of the importance of food, fluid and nutrition to holistic care and recovery Information Assurance At the start of the year, the Committee approved the Information Assurance Strategy and the Information Assurance Committee Workplan for At subsequent meetings, members considered and endorsed progress reports from the Information Assurance Committee, including a mid-year progress report and an Annual Report on the delivery of the Workplan for 2014/15. Members welcomed the confirmation that reports provided on progress across a number of areas, including: the operation of the FairWarning breach detection system; information security and the management of information breaches; information sharing partnership arrangements; and the continuing endeavour on staff training Internal Audit Report members noted the Internal Audit report for year ended 2013/14. Whilst the Internal Audit Review conclusion was satisfactory on the generality of the Governance Framework, the report contained recommendations for the Healthcare Quality Assurance and Improvement Committee, which were taken forward during the year Corporate Risk Register At each of its meetings, the Committee considered the clinical extract from the Corporate Risk Register, with the aim of maintaining an overview of clinical risk, and assuring that the risk descriptions and controls remain relevant. At the end of meetings of the Committee, consideration was given to any new risks identified during the course of discussion, or any issues highlighted in discussion which impacted upon the existing risk descriptions or controls Clinical Governance Corporate Dashboard At each meeting during the year, the Committee considered, in detail, the Clinical Governance Corporate Dashboard, to support the consideration given to the Dashboard by the NHS Board. The Committee received updates on progress in the development of an e-dashboard, and look forward to the availability of the Dashboard in this format Inspection of Services for Children and Young People Members received progress reports on the Joint Inspection of Services for Children and Young People in North

5 and South Lanarkshire. Both Inspections concluded in the latter part of 2014/15, and the Committee looks forward, in early 2015/16, to considering the inspection reports and recommendations, along with Action Plans to address any recommendations specific to Health and to multi-agency practise Medical Revalidation Submission and Annual Appraisal Report The Committee received an update on progress in the finalisation of the Medical Revalidation Submission and Annual Appraisal Report for the Staff Governance Committee and the NHS Board. This report was subsequently considered by the NHS Board in June The report was considered by the Revalidation/Appraisal Steering Group, and the relevant Clinical Governance and Risk Management Committees in the Community Health Partnerships and in the Acute Division. It was also shared with Healthcare Improvement Scotland as part of their Quality Assurance process for medical revalidation Research and Development The Committee considered a highlight report on Research and Development. Members welcomed the confirmation which the report provided of the extent of Research and Development in Lanarkshire, along with an indication of the actions planned for the coming six months, and the planning for the successful Research and Development Conference in March Organ Donation Members received and welcomed a highlight report on organ donation, with particular regard to the work of the Organ Donation Committee and maintaining and increasing donations where possible Reports and Decision Letters from the Scottish Public Services Ombudsman At each meeting, members considered Synopses and Action Plans to address recommendations from Scottish Public Services Ombudsman Reports and Decision Letters. During the year, members endorsed arrangements to strengthen assurance to the Committee about the progress and completion of Action Plans. Members also welcomed the focus on spreading learning from Reports and Decision Letters across Lanarkshire Local Supervising Authority Annual Audit Report 2014/2015: Monitoring the Standards of Supervision and Midwifery Practice The Committee considered the Local Supervising Authority Annual Audit Report, which was presented by the Local Supervising Authority Midwifery Officer. This, again, confirmed a high degree of compliance with the standards of supervision and midwifery practice in Lanarkshire Annual Reports Over the course of the year, the Committee considered and confirmed its satisfaction with Annual Reports in a number of areas, as follows: - Equality and Diversity Annual Report 2013/14 - Information Assurance Annual Report 2013/14 and 2014/15 - Public Protection Annual Report 2012/13 and 2013/14 - Healthcare Associated Infection Annual Report 2012/13 and 2013/14 - Feedback, Comments, Concerns, Complaints Annual Report 2013/14 - Voluntary Services Annual Report 2013/14 - Quality Assurance and Improvement Annual Report 2013/14 - Older People in Acute Care Annual Report 2013/14

6 4.25 Minutes During the course of the year, the Committee received and considered minutes of meetings of reporting groups, as follows: - Healthcare Quality Assurance and Improvement Steering Group - Risk Management Steering Group - Equality and Diversity Steering Group - Acute Clinical Governance and Risk Management Committee - Joint Community Health Partnerships Clinical Governance and Risk Management Committee - Care Assurance Board - Contract Monitoring Group 4.26 Operation of Healthcare Quality Assurance and Improvement Committee and Healthcare Quality Assurance and Improvement Steering Group During the course of the year, consideration was given to the future operation of the Committee and the Steering Group. This culminated in an event held on 13 th February 2015, at which detailed consideration was given to the operation of the Committee, going forward. The outputs and recommendations from that review will be considered by the Committee during the first half of 2015/ Terms of Reference The Committee maintained its Terms of Reference under ongoing review. Arising from this, the Terms of Reference were strengthened, specifically to articulate more clearly the Committee s responsibilities in relation to Public Health Governance. The subsequent amendments to the Committee s Terms of Reference were endorsed by the NHS Board in January Improvements Overseen by the Committee The principal improvements overseen by the Committee relate to: a) The implementation of the 21 recommendations from the Healthcare Improvement Scotland Rapid Review of Safety and Mortality b) The implementation of the recommendations from the Independent Review of Neonatology Services c) The implementation of the recommendations from The Francis Inquiry which were relevant to NHS Lanarkshire d) The implementation of the recommendations from the Vale of Leven Hospital Enquiry which were relevant to Lanarkshire e) The further roll-out of the Patient Safety Collaborative f) The progress during the year in implementation of the Care Assurance Accreditation System, with linkages to Person-Centred Care g) The implementation of recommendations arising from Healthcare Environment Inspectorate Healthcare Associated Infection visits, and the HEI acknowledgement of improvement evidenced at follow-up visits h) The continuing prominence given to Information Assurance, including the introduction of the FairWarning Breach Detection System

7 6. Matters of Concern to the Committee Matters of concern to the Committee relate to: a) The Healthcare Environment Inspectorate findings from the Healthcare Associated Infection Inspection undertaken at Hairmyres Hospital in September These related to concerns about environmental cleanliness and the cleanliness of near-patient equipment. It is recognised that absolute cleanliness 100% of the time will be difficult to achieve and maintain in extremely busy functioning acute hospitals, particularly within Emergency Departments. However, patients and the public are entitled to expect the highest standards of cleanliness within clinical settings. The NHS Board s declared commitment to delivering those expectations is acknowledged. Members therefore welcomed the immediacy and the thoroughness of the response to the HEI recommendations, and the associated endeavour to further strengthen the local monitoring arrangements, which included the introduction of a structured programme of Senior Manager Cleanliness Inspections. The progress of this initiative was reflected in a Report on Compliance With Environmental Cleanliness and Healthcare Associated Infection Standards, considered by the Committee on 9 April b) The Committee welcomed the comprehensive review of Primary care of Out Of Hours Services, the principal driver for which was the delivery of safe, effective, person-centred care. It is a concern to the Committee that the Primary Care Out of Hours Service has been operating in Business Continuity mode since mid This is not sustainable in the medium to longer term. Members, therefore, welcome the consultation on proposals for the future, which will be considered by the NHS Board on 27 May It is recognised that any decisions taken by the Board about the future configuration of Primary Care Out of Hours Services, can only be regarded as an interim measure, given the current national review of Primary Care Out of Hours Services, which is due to report in the latter part of It will be essential that any new arrangements introduced following the consideration by the Board of the consultation outcome on 27 May 2015, are monitored carefully, and members look forward to considering reports on the effectiveness of any new arrangements. c) Whilst reports to the Committee during the year confirmed compliance with the requirement for timely review of Corporate Clinical Policies, it is essential that the programme for the review and, as appropriate, updating of Corporate Clinical Policies, is strictly applied. It is recognised that this is currently the focus of ongoing effort, overseen by the Risk Management Steering Group. d) Although Clinical Governance Corporate Dashboard reports continue to be presented regularly to the NHS Board and the Committee, members have been concerned that the pace of progress in moving to the use of an edashboard. Whilst understanding the factors, including resource pressures and competing priorities within e Health, which have contributed to a longer lead time to availability and implementation, members are keen to see the edashboard introduced at the earliest opportunity, bringing, as it will, an enhancement to reporting on Key Performance Indicators for clinical governance.

8 7. Conclusion e) Members welcomed the additional measures introduced to provide assurance to the Committee on closure in relation to the delivery of action plans to address the findings of Scottish Public Services Ombudsman Reports and Decision Letters. It is essential that the strengthened focus in this area continues, in order that actions can be taken and lessons learnt, not only in the area giving rise to the complaint, but also in other appropriate areas across the system. From the review of the performance of the Healthcare Quality Assurance and Improvement Committee, it can be confirmed that the Committee has met in line with the Terms of Reference, and has fulfilled its remit. Based on assurances received and information presented to the Committee, adequate and effective Healthcare Quality Assurance and Improvement and Information Assurance arrangements were in place throughout the year.