Minutes of the Quality Governance Assurance Committee held on the:

Transcription

1 Minutes of the Quality Governance Assurance Committee held on the: Date Wednesday 22 July 2015 Venue Boardroom, G099, Building 12 Time 2.00pm to 4.00pm Name Role Present: Dr J Anderson (JA) Chair n-executive Director M Arthur (MA) C Etches (CE) D Loughton (DL) G Nuttall (GN) Dr J Odum (JO) J Vanes (JV) Head of Governance & Legal Services Chief Nursing Officer Chief Executive Chief Operating Officer Medical Director Chairman of the Trust Attendees Rachel Overfield (RO) Trust Development Authority Apologies: R Edwards (RE) n-executive Director T: Committees/QGAC/July 2015 Page 1 of 14

2 1 Apologies for absence Apologies were noted. 1A Declarations of Interest There were no Declarations of Interest. 2 Minutes of Previous Meeting The minutes were accepted. JA asked for an update on 4.1, page 2 if the Cancer Intensive Support Team had been invited to review the Urology Pathway around 62 days. GN confirmed that they had been invited and there is currently a waiting list which we are on. DL reported that a new Consultant had been appointed. JA asked for an update on 5.2, page 7 if the software update due for Ward Performance Monitoring has been installed. CE replied that it was in fact Vital Pac and it had not yet been installed. The company who were supplying Vital Pac could not give CE an update on when they would be able to install. CE has tasked Rose Baker, Head of Nursing Division 2, to clarify with the Company if other organisations are being upgraded and if so what with and secondly the organisations who have been upgraded what are they doing with their IPod 4 s. There is none available commercially and RB is to ask the question if this Trust can borrow / be given them. CE raised a concern that if the company has no idea when the new system will be installed or if we cannot borrow / have some IPod 4 s the Trust will have to revert back to a paper system. The meeting agreed that this was not ideal. DL to speak to Nick Bruce regarding IPod 4 s. RESOLVED: Minutes of the Quality Governance Assurance Committee held on 24 June 2015 was approved as a correct record. DL 3 Matters arising from the Minutes The matters arising from the Minutes were updated on the action log sheet and closed. 4 Regular Reports 4.1 Integrated Quality & Performance Report G Nuttall / C Etches GN presented the performance section of the report. Due to the performance section of the report being discussed in Finance & Performance Committee earlier in the day, JA agreed for GN to highlight key points. GN informed the meeting that the Trust is currently predicting a possible failure of the 62 Day Screening and 62 Day Referral to Treatment target for June; however this data is still being validated. The meeting was informed that the final cancer data is uploaded nationally 6 weeks after month end. T: Committees/QGAC/July 2015 Page 2 of 14

3 GN reported that the A&E department continues to see an increase in attendances in June, an increase of 3.16% compared to the same period last year. One day in June saw the busiest day ever by the Trust with a record attendance of 413 (previously 394). The Trust failed to achieve both Type 1 and All Types for the month. In July to date, there have been 107 attendances in the first 15 days of the month; this is an increase of 1.84% on last year s attendances. GN informed the meeting that PWC have been jointly commissioned by us, CCG and the Local Authority to review delayed transfers. They are currently on site and will report back in 4 weeks time. Workforce / recruitment were discussed at the Finance & Performance Committee in the presence of Angela Adimora. Cancelled operations for June are green for the first time in a considerable amount of time. JA asked GN about the 1 patient in A&E who had been waiting on a trolley for over 12 hours. GN replied that and internal RCA has been undertaken and this has been forwarded to the CCG to form part of their investigation / RCA for this incident. GN reported that the incident was reported to the Trust Board. GN explained the reasoning behind the delay. The meeting discussed the impact of the incident on the Trust and the patient. JA commented that the Trust is making progress on reaching the targets in regards to the Discharge; however the Trust is still below target. CE presented the Quality report. CE asked the meeting to ignore the data within the Pressure Ulcer section of the Executive Summary; the data is not all accurate. The heel boots are now available to offload pressure from heels. The meeting learnt that each service with avoidable pressure ulcers have comprehensive action plans being monitored. CE reported that the overall Trust response rate for June in regards to complaints was 71%; this is an improvement of 19% on the previous month. In June, 6 complaints took longer than 35 working days to investigate and respond (5 with consent to breach and 1 with no consent to breach). CE confirmed that she is meeting with all the Directorates who breach on a weekly basis. The Trust Complaints Policy is under review to allow for 30 days flat line response. CE confirmed that she will update the Committee as and when. CE informed the meeting that the Family & Friend Response rate is currently quarterly and not monthly. CE assured the meeting that future reports the figures will be monthly. The A&E FFT response rate is above the target however the Inpatient FFT is below the target but above England s target. Division 1 are more consistent in their response rate and that may be because they have a lot of elective patients. The meeting was informed that there have been 2 Duty of Candour Breaches within June. CE reported that these breaches were in section 2 and this was the sharing of the outcome of the investigation with patients / relatives. This sharing is due within 10 working days of the final RCA report being submitted to the CCG. T: Committees/QGAC/July 2015 Page 3 of 14

4 CE reported that there had been an increase in pressure ulcers for the Trust and not a decrease as stated in the report (page 10). CE informed the meeting that the Trust is stable for RWT acquired pressure ulcers. JA queried unavoidable pressure ulcers being reduced from 66 in May to 46 in June. CE explained that the figures to JA and the rationale behind them. There has been a slight reduction of patients with any harm from a fall and UTIs and Catheters. However the Trust has shown a slight improvement in June for harm free care (Safety Thermometer), CE assured the meeting that it is not a significant issue to the Trust. Clostridium Difficile indicated 10 positive cases in June with 5 being attributed to the Trust. This is against a target of 3 for the month. To date this now means we are 12 cases over target at the end of month 3. JV mentioned that there had been 1 MSSA case in June. The Trust target is 24 for the year; so far the Trust has had 2 cases this year so the Trust is currently well within target. The WHO checklist compliance is still at 100% for June for theatres. Division 1 had 1 Safeguarding Adults referral and Division 2 had 3. One of the referrals within Division 2 had been triggered by the CQC and their request to follow progress. There was an increase in falls per 1,000 occupied bed days in June of All RCA s are completed on harm caused falls. CE to invite NHS England to review falls within the Trust. CE The meeting was informed that there was a dip in C Section rates in June and the Trust is currently above target of 0.1%. The percentage of 3 rd & 4 th degree tears is now above target (3.5%). JA noted that there was an increase in unexpected term babies to neo natal unit in June. Midwife to birth ratio is currently stable. CE reported that there was a slight decrease in smoking at delivery. JO reported that the SHMI for the Trust is just below 1 and the HSMR is just above 1. The CQC have requested a report in connection with deaths in relation to Acute Renal Failure. JV commented that the mortality figures seemed to have settled and asked if this was across the country. RO reported that there was consistent movement in some Trusts. JO explained HED to the meeting. JA queried medication incidents as this report had no incidents causing serious harm but the QSAG report indicated that there was 1 with harm. CE agreed to investigate. CE Resolved: Report was accepted 4.2 Board Assurance Framework / Trust Risk Register M Arthur MA presented the BAF and TRR report to the meeting. MA informed the meeting that there were no new risks within BAF and 3 existing red risks: SR8 That there is a failure to deliver recurrent CIPs, T: Committees/QGAC/July 2015 Page 4 of 14

5 SR9 That financial balance (and surplus) is not achieved SR12 That the retention and development costs of staff are unaffordable. There were no closed risks and a total of 10 (on-going) risks are currently being managed within BAF. On the TRR there were no new risks, no red risks and 3 risks closed: 4172 Supply Disruption of Baxter Colleague Pump compatible IV administration sets and Baxter blood admin sets, 2965 Never events risk transferred from BAF 3645 The short term impact on the Trust of service sustainability in Staffordshire risk transferred from BAF. Within TRR there are currently 17 (on-going) risks being managed. The meeting agreed that BAF risk SR4 risk of adverse impact on the Trust following service transfer in vember 2014 and changes uncertainties within the Staffordshire Health Economy should now be transferred to the Chief Operating Officer and be discussed within Finance & Performance. There are no BAF risks allocated to QGAC for management. Risk SR5 If competition causes a significant shift in activity MA advised the meeting that some controls are updated quarterly. Risk SR6 Potential impact on income due to enacted intentions of Commissioners the meeting discussed this risk and agreed to move to Finance & Performance Committee as there is no such a committee as Contracting & Commissioning meeting. Risk SR7 That the financial risk of vertical integration is prohibitive - the meeting agreed that this should be with TMC and Finance & Performance Committee. Risk SR8 That there is a failure to deliver recurrent CIP s Month 2 CIP target has been met, however the CIP target is phased into the latter part of the year. Risk SR9 That Financial balance (and surplus) is not achieved awaiting outcomes of business cases. There are no changes to the remaining 4 risks. JV asked about TRR risk 2680 overspend on interpreting and translation budget could lead to inadequate funding and service to patients CE explained that ideally the Trust would like to use telephone interpretation. The meeting discussed the possibility of not using any form of interpreters and the risk of using family / friends to interpreter. JV asked about TRR risk 1713 failure to effectively maximise workforce productivity; failure to routinely review consultant job plans JO assured the meeting that the job planning process was close to be implemented. MA MA MA T: Committees/QGAC/July 2015 Page 5 of 14

6 Resolved: Report was accepted. 5 Sub Group Reports Patient Safety Improvement Group minutes C Etches The meeting accepted the minutes. Chairman s Report 1. VTE Challenges continue with the collection of data around VTE compliance. This has been an ongoing issue for some month/years and PSIG agreed a new approach needs to be sought. It agreed to set-up a Task and Finish group to process map current practice and redesign a new system of working. This would need to include Junior Doctors who are closer to the issue. Dr Wilmer is standing down from her lead role and a new lead will be identified. 2. Safer Surgical checklists Most directorates are compliant with the use of and completion of checklists. However, a few directorates appear to struggle to maintain 100% compliance. It was agreed for Divisions to manage this directly, if no sustained improvements seen the directorates will be invited to PSIG to account for gaps in practice. 3. Patient Experience A new strategy for patient experience and engagement is under development. PSIG shares concerns over the urgent need to improve the timeliness and quality of complaint responses. Chief Nursing Officer is to meet with directorates following a breach in standards (consent and response times). 4. Lessons Learnt The detail of individual themes was shared with PSIG members. Sharing lessons across the Trust will be communicated by a number of methods: Risky Business newsletter quarterly Making it Better Alert Weekly briefing Whilst the group will focus on themes there is also some work in progress to seek assurance of actions closed following incident/ complaint/litigation. Resolved: Report was accepted Quality Standards Group Minutes C Etches Chairman s Report 3.1 Clwyd Hart Report An update on the implementation of the recommendations made in the Clwyd Hart review of 2013 was presented. Broadly speaking the recommendations can be broken into Trust T: Committees/QGAC/July 2015 Page 6 of 14

7 specific and national/non Trust specific recommendations. The report set out the recommendations clearly and provides a narrative around work required to be undertaken to achieve compliance, and/or where the Trust is already compliant. Time scales are set against each relevant recommendation. 4.1 Health and Safety Steering Group The health and safety annual report was presented and was clearly set out as a RAG rated dashboard for the individual domains, with a clear explanation around the actions required to achieve a green rating for each domain. Time scales for each of the domains is clearly set out. JO asked for it to be noted that the report was very well presented by Margaret Simcock. 4.2 National Guidance Annual Report With respect to national guidance and reports further work is required around both assurance and reassurance around compliance with recommendations made in these reports. Also the RAG rating for individual reports requires clarification around methodology. The governance team will review the processes in line with the discussion at QSAG. 4.4 Radiation Safety Group Further work is required to ensure that all staff who require radiation training have undertaken the training. Radiation training is mandatory and is required to ensure that the Trust remains compliant. 4.5 CIPOLD Premature Deaths of People with Learning Disabilities Update Report This report highlighted an urgent requirement to ensure that appropriate information sharing is available regarding people with learning disabilities. Also, needs to be an education programme regarding patients with learning disabilities and also those who lack capacity across the Trust, with the raising of awareness of the issues and implications of ensuring that the Trust and staff are complaint with the Mental Capacity Act. 4.6 Internal Pilot Quality Review Visit Report Out Patients Department 1 A very positive report was presented around the internal CQC style visit to OPD1. The report was well received and was very clear. Resolved: Report was accepted Routine Reporting / Themed Review s Claims & Litigation Report M Arthur MA presented the Claims & Litigation Report to the meeting. The meeting noted that the report covered the period between 1 April 2014 and 31 March 2015 inclusive. During this period there were 156 new Clinical Negligence cases, which was an increase from 129 claims in the same period last year. A total of 31 claim are open and ongoing from MSFT (majority derived from Trauma and Orthopaedics and Obstetrics and Gynacology). Within Division 1 there were 99 new claims T: Committees/QGAC/July 2015 Page 7 of 14

8 the main areas being General Surgery and Obstetrics & Gynaecology. Within Division 2 there were 57 new claims, the main area being A&E Services. There are currently 344 on-going clinical negligence claims (an increase from the previous reporting of 282). During the period of April 2014 and March 2015, a total of 93 CN claims have been closed. The number of new claims in the period exceeds the number of closed claim which explains the significant number ongoing claims and the pace of claim closures. For new Personal Injury claims there were 62 new claims received in comparison with the previous year of 51. The Trust received 4 claims within this total from MSFT on the 1 vember The meeting discussed why this Trust was handling MSFT claims post day 1. It was explained that during separation planning agreements were to split the civil litigation cases pre day one based on a combination of service/staff transfers. After discussion it was agreed MA would speak to the relevant persons at Cannock, clarify the situation with the 31 claimants and report back to this meeting. JO commented that the file closure notes and lessons learnt are interesting to read and are beneficial to the directorates. It is currently left to the directorates to ensure actions are noted, learnt and implemented. Divisions are copied into the notifications. The meeting heard that the Trust is getting on top of sharps issues and lessons are being learnt. There has been a progressive reduction in the number of successful sharps claims received and settled over the past months. There were 13 inquests between April 2014 and March resulted in a verdict of neglect MA advised the meeting that the workload had increased within inquests due to the number of Inquests where the Coroner is implementing a quicker turnaround period of approx. 6 weeks from notification to completion. Resolved: Report was accepted. MA 7 Issues of Significance for Audit Committee The BAF format and allocation of risks Chair Issues of Significance for Trust Board Chair Integrated Quality and Performance Report Improved response to complaints this month but still problems with getting timely consent to breach. Policy (PHSO) review recommends response time is unified at 30 days. Standards will continue to be monitored by CNO Cancelled operations met target for quarter 1 Slight increase in avoidable pressure ulcers. Heel boots now available (Help to Heel campaign) Falls higher this month. New policy being audited. NHS England being asked to come and review practice. T: Committees/QGAC/July 2015 Page 8 of 14

9 C. difficile continues over target. Being fully reviewed through IPPG. Ward decanting for deep cleans has begun. Obstetric directorate being asked to come to October QGAC to discuss numbers of 3 rd and 4 th degree perinatal tears and admission of full term babies to NNU for level 3 care. Improvement in reaching targets for discharge summaries with further improvements being expected by September Board Assurance Frame work and Trust Risk Register New BAF format continues to be embedded. 3 red risks all being reviewed by F&P as are other risks on the BAF (total 10) reds on TRR. Never Events being monitored at directorate level ted discharge delays for social care have increased in last 8 months. Further discussions around winter pressures to be discussed Overspend in interpreting services of concern. Alternative management systems to be investigated New consent process being rolled out Patient Safety Improvement Group VTE. Change to lead clinician. Recorded compliance remains an issue. Task and Finish group to investigate gaps in assurance where assessment done and treatment given but not documented. Safer surgical checklists indicate some directorates do not always meet internal target of 100%. Divisions to manage in first instance. Sharing lessons across the trust triggered by incident or external event being strengthened by a number of methods. Quality Standards Group Clwyd Hart report reformatted for Trust use. Improved handling of complaints being rolled Further work required regarding radiation safety; mandatory training required for all who order X-rays. CIPOLD report requires urgent action to ensure all staff are able to recognise those with learning disability and /or lack capacity to ensure their clinical needs (and other needs) are fully met. Internal quality visit to OPD 1 very positive. Claims & Litigation Report Increase in new claims received in last financial year (156 cf 129) however size of organisation has grown considerably during year. Diagnosis claims highest in ED, O&G and in Surgery treatment categories. Lessons learnt from claims are circulated to directorates and divisions. Increase in personal injury claims mostly slips trips and falls and needle stick injuries mostly from Estates and Facilities. However needle stick have progressively reduced due to change in type of needles used and the Sharp s policy has been reviewed. Only two Coroner s inquests resulted in verdicts of neglect (total 19 closed). T: Committees/QGAC/July 2015 Page 9 of 14

10 8 Evaluation of Meeting ALL This item was not discussed. 9 Any Other Business ALL Review QGAC Schedule of Reports / Themed Reviews Maria Arthur MA advised the meeting of the reports and themed reviews that were being removed. These were agreed by the meeting. MA to make the necessary changes. MA 10 Date and time of Next Meeting: Wednesday 23 September 2015, 2.00pm to 4.00pm, Boardroom, G099, Building 12 Please note the new time of this meeting. Apologies Dr J Odum T: Committees/QGAC/July 2015 Page 10 of 14

11 COMMITTEES ACTION SUMMARY REPORT ITEM to be taken raised from the meeting Lead Committee Date Review date 2 DL to speak to Nick Bruce regarding IPod 4 s DL to ascertain if the Trust is able to purchase / obtain any. 4.1 There was an increase in falls per 1,000 CE occupied bed days in June of All RCA s are completed on harm caused falls. CE to invite NHS England to review falls within the Trust. 4.1 JA queried medication incidents as this report CE had no incidents causing serious harm but the QSAG report indicated that there was 1 with harm. CE agreed to investigate. 4.1 MA to update the TRR & BAF risk registers. MA MA to clarify the situation regarding the 31 legal cases that have been transferred over from MSFT. 9.1 MA to update / make changes on the QGAC Schedule of reports / themed reviews for this meeting. 4.1 June 15 JA queried the number of unexpected term babies to Neonatal unit, in May there were 3 unexpected admissions. This was discussed indepth and It was agreed to provide brief detail for each full term baby admitted to the neonatal unit unexpectedly to enable this meeting to note any trend or concern regarding care. CE agreed to do the action. MA MA CE Update CE confirmed that the Directorate will come and present to the October QGAC. CE has received a letter regarding 3 rd & 4 th degree tears. National Midwifery guidelines have been reviewed and the Trust will now be adhering to them. T: Committees/QGAC/July 2015 Page 11 of 14

12 4.1 Feb 15 CE raised concerns that we are still breaching around consent in regards to complaints. CE will be meeting with Carol Bott to discuss complaints and the changes not having a positive impact. CE agreed to update the meeting on any progress made CE GN informed the meeting that this was discussed at the last QSAG meeting and QSAG have asked for additional work to be done on the report and represent again. B/F April 2015 RE reported that QSAG have asked for additional work to be undertaken MA advised the meeting that in Carol Bott s absence Paul Archer is covering / supporting the work within the Patient Experience team. PA advised the meeting of the current situation and after discussion it was agreed that the report / update should go to QSAG for assurance. The assurance should then be escalated to this meeting CE reported that Carol Bott is back from sickness and CE has spoken to Paul Archer in regards to where are we at with the league tables for Directorates. Work is on-going which includes a dashboard to come to here and Trust Board. T: Committees/QGAC/July 2015 Page 12 of 14

13 Closed Agenda s To be removed at the next meeting ITEM to be taken raised from the meeting Lead Carried forward from Committee Review date Update 4.1 June June 15 RE asked why the WHO Surgical Checklist Compliance had a target of 98% then 97% when it should have been 100%. Following this RE queried TRR 2965 and said she found it very confusing. CE agreed to check the WHO target and it should be at 100%. Risk 2965 if the Trust fails to learn from and reduce Never Events, this will have an adverse impact including patient experience and choice, CQC/TDA/media interest, loss of public confidence etc - the meeting agreed for it to be closed on TRR with rationale that a Never Events risks are managed on both Divisional risk registers and is suitable for local management.. Also high levels of compliance with the WHO safety checklist have been consistent and reporting continues at Patient Safety Information Governance. RE asked MA if this risk, which indicates a negative assurance which states 64% compliance, if the areas within Division 1 that this pertains to could be added to Datix. CE CE reported that our internal target is 100% but the CQUIN target is 97%. Close MA MA reported that this risk was now closed. The 4 areas that this risk was related to was: ICCU, Obs & Gynae, Children Services. This is now closed. T: Committees/QGAC/July 2015 Page 13 of 14

14 4.2 June 15 After discussion regarding workforce issues on the BAF and why it is levelled at red, the Committee asked MA to meet with Angela Adimora to review her BAF risk regarding grade and content. Following this meeting MA to feedback to this Committee and Sukhbinder Khunkhuna. MA This has now been resolved and is now classed as amber 4.2 June June June May 15 The Committee asked if the BAF could be printed on A3 paper for reading purposes. The Committee agreed that once the proposed changes to responsibilities and membership had been made by MA, these would be submitted to the Trust Board on Monday for approval. The Chair asked CEm to circulate the agenda plan for the next 12 months to the next meeting. MA to make the mentioned changes to the QGAC TOR and circulate. To be approved at the next meeting. CEm Completed MA Completed CEm Completed MA On the agenda Completed T: Committees/QGAC/July 2015 Page 14 of 14