DRAFT NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST QUALITY ASSURANCE COMMITTEE

Transcription

1 DRAFT NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST QUALITY ASSURANCE COMMITTEE MINUTES OF THE MEETING HELD ON 18 NOVEMBER 2015 IN THE BOARD ROOM, TRUST HQ, CITY CAMPUS Present: Professor H. Sewell Mr D. Cartwright Dr S. Fowlie Ms N. Hill Dr P. Homa Mrs C Shaw Ms M. Sunderland Dr J. Tabreham Non-Executive Director (Chair) Associate Non-Executive Director (Non Voting) Medical Director Director of Human Resources Chief Executive Chief Operating Officer Chief Nurse Non- Executive Director In Attendance: Mr A. Chatten Director of Estates and Facilities Management Mrs K. Kirkwood Associate Director of Assurance (Committee Secretary) Mr M. O Daly Trust Secretary Ms J Pidgeon* Supervisor of Midwives (for agenda item 1.6) Ms C Posaner* Supervisor of Midwives (for agenda item 1.6) Dr S Roe* Head of Renal Services (for agenda item 2.1) Sister B Dring* Renal Dialysis Sister (for agenda item 2.1) Mr M Bolton* Deputy Programme Director (for agenda item 2.2) Mrs N Lindley* Tissue Viability Lead Nurse (for agenda item 2.3) Mr A Riley* Matron for HCOP (for agenda 2.4) Ms J Rossell* Divisional General Manager for Medicine (for agenda item 2.5) Dr A Shetty* Head of Stroke Services (for agenda item 5.2) * Present as indicated Cumulative Record of Quality Assurance Committee Members Attendance (2015/16) Name Possible Actual Ms L. Scull 6 6 Professor H. Sewell 8 8 Dr J. Tabreham 8 6 Mr D. Cartwright 8 4 Dr P. Homa 8 7 Dr S. Fowlie 8 8 Ms M. Sunderland 8 7 Mr T. Guyler 1 1 2

2 Mrs C Shaw /250 08: /251 08:31 Introductions / Welcome The Chair welcomed all present and in attendance to the meeting. Apologies for Absence Apologies for absence were received from: Ms L. Scull (Trust Chair) 2015/252 08:31 Declarations of interest on agenda Items Dr Tabreham highlighted the following in regard to her pre-existing declarations (in brackets) in the register: Agenda items 2.4 & Parliamentary and Health Service Ombudsman Issues (Non Executive Director to the Board of the Parliamentary Health Service Ombudsman) The committee agreed that Dr Tabreham need not absent herself from the meeting in regard to the specified items. 2015/253 08: /254 08: /255 08:36 Minutes of the meeting held on 21 October 2015 The minutes of the meeting held on 21 October 2015 were agreed as a true record. Review of committee action log The committee reviewed the committee action log and noted the progress reports against the actions due to have been completed ahead of this meeting. Matters Arising from the Minutes Commentary on response to section 8 of LSA report Ms Pidgeon and Ms Posaner, the two new full-time supervisors of midwives, attended the meeting to report on the actions taken to address the points raised in section 8 of the 2014 LSA audit. The appointment of two full time supervisors of midwives (SOM) had increased the visibility of the SOM in all midwifery areas and led to more positive feedback from staff in the 2015 LSA audit which had recently taken place. In addition, the changes to the midwifery matron roles had provided more continuity of support and advice for staff. Ms Sunderland updated the committee on the national focus with respect to 3

3 supervision by the NMC. Dr Tabreham asked how the role linked into midwives supporting women choosing home births. The SOMs were directly involved in the home birth users group, signposting women to resources and supporting choices. Revised maternity risk management action plan more detail had been added to the plan. In answer to a question from the Chair, it was confirmed that a local midwifery acuity tool was being worked on. The Chief Nurse had commissioned an external review of the maternity service from an occupational psychologist. The Chair thanked Ms Pidgeon and Ms Posaner for the assurance that could be taken from the update reports. 2015/256 08:50 Report from Head of Service on actions taken as a result of the Hepatitis B serious incident Dr Simon Roe and Sister Belinda Dring attended the meeting at the committee s request to give assurance about the actions being taken to avoid a recurrence of the serious incident in the dialysis unit. Dr Roe briefly recapped on the incident itself which had left ten patients potentially exposed to a blood borne virus as a result of a breakdown in guidelines relating to isolation and segregation. One patient had been suspended from the transplant list for a period of three months as a result of the incident. The service had reviewed the routes of entry into the dialysis unit and had widened the responsibilities of the whole team involved in the pathway. A clear standard operating procedure had been written to accompany the guidance, supplemented by a transfer sheet and an additional clinic visit prior to first dialysis. A dialysis safety checklist had also been implemented. Dr Roe assured the committee that the action plan was largely complete. In answer to a question from the chair, Dr Roe confirmed that following advice from infection, prevention and control, three months of additional surveillance had been required for the ten patients and that a robust audit system of the new processes was in place. Dr Roe confirmed that the duty of candour requirements had been met. The chair thanked Dr Roe and Sister Dring for providing the committee with the update and associated assurances. 2015/257 09:02 Readmissions quarterly report Mr Bolton attended the meeting to present the quarterly report on readmissions. 4

4 Performance was improving and our 2015/16 quarter two readmit rate was an historic low. Significant progress had been made in elective and cancer services. As a result of meeting both its quarter one and two targets, 3.3 million income had been earned by the Trust. Work was ongoing on a communication link to the initial discharging team when a patient was readmitted. Dr Fowlie asked about the impact of the surgical triage unit and the cancer admissions taskforce. Mr Bolton agreed to include some narrative about this in the next quarterly report. In answer to a question from Dr Tabreham, Mr Bolton confirmed that Connected Nottinghamshire was sighted of this work and NUH was working with community colleagues on an information sharing agreement. The chair thanked Mr Bolton for a clear and succinct report. 2015/257 09:13 Pressure ulcer quarterly report Mrs Lindley attended the meeting to present the quarter two pressure ulcer report. In summary: Stage 4 hospital acquired avoidable & unavoidable pressure ulcers There had been no Stage 4 hospital acquired pressure ulcers. The last stage 4 pressure ulcer (which was deemed avoidable) occurred in April Stage 3 hospital acquired avoidable pressure ulcers Continued improvements were seen and the Trust had exceeded its target once again in Q2. Stage 2 hospital acquired avoidable pressure ulcers In Q2 there had been further improvement but the Trust remained behind its ambitious target (reducing avoidable pressure ulcers by 50% over three years). In addition, the September 2015 safety thermometer results saw NUH s best performance to date with the prevalence rate well below the national average. Ms Sunderland commented that these results were a reflection of the high standards of nursing care being provided at NUH. The chair asked about the Trust s target reduction for avoidable stage two pressure ulcers. It was confirmed that this was a very ambitious target, set 5

5 by NUH itself, and was perhaps worthy of reconsideration by the nursing and midwifery board. The Trust was running a number of practical sessions during the week, which was international pressure ulcer week, at which the outcomes from the pilot wards were being shared. The chair thanked Mrs Lindley for her very positive report. 2015/258 09:19 Parliamentary and health service ombudsman report and action plan HCOP Mr Riley attended the meeting to present the outcome of a parliamentary and health service ombudsman complaint about care in the HCOP service which had been partially upheld by the ombudsman. Mr Riley described the issues raised by the complaint which essentially related to: Nutrition and hydration Oral hygiene Complaint handling The action plan had been managed to completion. In response to a question from Ms Hill about the broader learning across the Trust from this report, Ms Sunderland replied that the findings were built into existing Trust-wide workstreams and benchmarking programmes. She added that the new ward dashboards, which were in the final stages of development, would give real time information on a number of key nursing indicators. A total review of the Trust complaint handling processes was underway, the outcome of which would be reported to the committee in January In answer to a question from Mr Cartwright, Mr Riley confirmed that the approach of the Trust to complaints was always local resolution in the first instance. Ms Sunderland and Dr Fowlie were currently reviewing all complaint responses on behalf of the Chief Executive and feeding back to authors in order to create a culture of continuous improvement rather than defensiveness in complaint responses. 2015/259 09:35 Winter resilience bed capacity and bed reconfiguration update Mrs Shaw introduced the paper and presentation on the Trust s winter resilience bed capacity and bed reconfiguration update. She apologised for the poor quality of the circulated paper and explained that the plans for 6

6 winter 2015/16 had undergone a series of changes owing to unforeseen ward closures. Ms Rossell presented the series of options that had been considered in order to increase both respiratory capacity and medical outlying capacity, principally on the City hospital campus, but now with eight additional beds on the QMC campus 30 additional beds in total. The enablers and risks of the plan were detailed in the presentation. In response to a question from the chair about the two significant estate issues on the City campus, Mr Chatten explained the reasons for both and the plans for addressing these. Mrs Shaw emphasised the essential need for fully equipped decant wards on both campuses which could be flexed seasonally. Ms Rossell confirmed that the beds would be ready to open in December 2015 and that respiratory nurse staffing would be available. The stroke service and hospital at night service required additional medical support which was being organised. Dr Tabreham asked if the recent research into the inappropriate use of asthma medication was being considered and it was confirmed that the Trust s respiratory working group would take the lead on this. Mrs Shaw informed the committee that a proposal had been submitted to the local CCGs for the provision of step down care with medical support in the community (28 beds). If successful, this would help address approximately a third of the patients within HCOP with delayed transfers of care. The committee agreed to receive quarterly updates on progress with this plan. 2015/260 09:57 Serious Incident Log Dr Fowlie presented the monthly update which was received and noted by the committee. He drew the attention of the committee to two incidents on the log the salmonella paratyphi A incident, the report of which had been circulated to the committee; and secondly, the cardiac surgery incident, for which an extension to the timeline for investigation had been agreed. Dr Fowlie notified the committee of two serious incidents, both classified as never events, which had occurred in November 2015, after the log had been finalised. The Board and external partners had been notified about both incidents in the usual way by Dr Fowlie. 7

7 The first incident related to oral medication having been administered intravenously in a research setting. The investigation was being coordinated jointly by the hospital and the university. The second incident related to a wrong surgical implant during maxillo-facial surgery. Both incidents had resulted in low patient harm. The outcome of the investigations into both incidents would be presented to the committee in line with incident reporting procedures. 2015/261 Outcome of serious incident investigation into laboratory acquired salmonella paratyphi A infection Dr Fowlie presented the summary of a serious incident investigation into a case of laboratory acquired salmonella paratyphi A infection. The findings and recommendations from the investigation were supported, especially in relation to the restricted use of mobile phones in rooms adjacent to laboratories; the processes for handling blood cultures and rigorous standards of hand hygiene within the laboratories. Dr Fowlie agreed to obtain additional information about the categorisation of risk to blood culture samples. The committee received and noted the report. 2015/262 10:23 Nurse staffing monthly report Ms Sunderland presented the monthly report on nurse staffing. She highlighted the following issues to the committee: The nine workstreams in place to ensure good recruitment, retention and safe nurse staffing The work to avoid the use of non-framework agencies The controls on the use of temporary staffing The improved intelligence from use of the staffing app (linked to harm data) Continuous improvement against the e-roster key performance indicators Successful overseas recruitment The commencement of a reduction in ward vacancies The Trust had been asked by the Department of Health to make the NUH staffing app available nationally. The app had won an innovation award which was attracting national attention. The chair commented on the excellent quality information provided in the report. 8

8 Ms Sunderland reported that 150 nurses were currently within the recruitment system, some of whom were part of the recruitment for the winter plan. The committee received and noted the monthly report. 2015/263 10:28 Outcome of TDA infection control visit October 2015 In response to a further TDA infection control visit in October 2015 a new action plan with four fundamental elements had been agreed and was now being implemented. Whilst significant improvement had been noted in a number of areas, this had not been universal and three members of staff had been removed from their substantive roles on a temporary basis, whilst issues of clinical leadership were addressed. A planned re-visit by the TDA had been scheduled for early December /264 10:43 Medical devices annual report Dr Fowlie presented the annual medical devices report to the committee. The committee specifically noted the progress that had been made with the annual preventative maintenance of high risk medical devices and the key risk highlighted in relation to loan medical devices. The committee received and noted the report. 2015/265 10:45 Patient safety conversation mid-year report The committee received and noted the mid-year report on the number and outcome of Board patient safety conversations across the Trust. The committee commended the report and felt that it gave an authentic account of these important safety conversations. Dr Fowlie confirmed that the annual report would include greater detail about the actions taken in relation to the issues raised during these conversations. The chair highlighted the number of estate issues that were brought to the attention of Board members during these conversations and the need for these to be taken account of in the preventative maintenance and capital programmes. 9

9 2015/266 10:52 Mortality dashboard Dr Fowlie presented the monthly report. The Trust was still alerting for HSMR but not for SHMI and crude mortality. The Board would receive a more detailed report on mortality at its November meeting. The committee received and noted the report. 2015/267 10:55 Parliamentary and health service ombudsman report and action plan Stroke Dr Shetty attended the meeting to present the outcome of a parliamentary and health service ombudsman complaint about care in the stroke service which had been upheld by the ombudsman. Dr Shetty described the issues raised by the complaint which essentially related to: Delay in prescribing and administering Aspirin Delay in reviewing a CT scan Frequency of patient monitoring Timely use of thrombolysis The action plan had been managed to completion. The chair asked about the use of AVPU (alert, voice, pain, unresponsive) a system for measuring and recording a patient s responsiveness, indicating their level of consciousness. Dr Shetty confirmed that staff were adequately trained in AVPU but that in this case it had not been carried out as frequently as it should have been. Mr Cartwright commented on the delay in processing the ex gratia payment and the need for more speedy resolution of complaints. The chair thanked Dr Shetty for attending to present the report and action plan. 2015/268 11:02 CQC compliance report effectiveness domain The Trust had undertaken a full peer review in all wards and departments of compliance with the CQC fundamental standards linked to the effectiveness key lines of enquiry. Overall, the Trust had self-assessed itself as good in relation to meeting these standards. Mrs Kirkwood drew the attention of the committee to a notification that had been received from the CQC that it would not be publishing any further 10

10 updates of its intelligent monitoring reports. The rationale for this was that by March 2016, all NHS acute and specialist Trusts will have had an inspection using the new CQC comprehensive methodology and the CQC will be pursuing a new strategy from April 2016 which will include the development of smarter monitoring and strengthening insight from data. At the end of October 2015, the CQC published the basis for developing its new strategy and future approach to the quality regulation of health and social care services in Building on Strong Foundations. Consultation on the proposed new strategy will commence in the New Year, but this publication presages some of the likely changes: Risk-based registration Smarter monitoring and insight from data A greater focus on co-regulating with providers More responsive and tailored inspections 2015/269 11:07 PLACE report and action plan Mr Chatten presented the results of the 2015 Patient Led Assessment of the Care Environment (PLACE) inspection which had taken place in April and May The report focused on the cleanliness and condition of our patient environment and the quality of our food service provided to the patients. Mr Chatten confirmed that there had been some continuity in the PLACE assessors, although it was recognised that the PLACE process was subjective and that authentic comparisons were difficult to make. There were no serious outliers between NUH and the national average, although there were differences between the QMC and City Hospital campuses. This was the first year that the dementia domain had been included as a scored element and the findings had provided lessons for refurbishment and maintenance of the estate going forward. The Trust had introduced a system of PLACElite inspections, the most recent of which had taken place at the beginning of November on both main campuses. A number of areas had been re-visited and some new areas inspected. Some improvements were noted, but there were still some issues to be addressed. Dr Fowlie made two observations in relation to the report the need to qualify the statement about year on year improvements and the need to 11

11 avoid comparison with the national average given the inspection process does not include a moderation or consistency check. 2015/270 11:20 Directorate/division quality review update The committee received and noted the update on the outcomes of the quality governance review system which had been introduced in October An internal audit review of the system had given a significant assurance opinion. With the move to the new divisional structure and as part of the new streamlined governance architecture for the Trust, it has been agreed to combine the performance and quality governance review meetings into one combined monthly meeting with divisions covering the domains of: Quality Finance People Performance The first combined meetings were held during the first week in November and it was clear that there was a need to agree revised data sets for these meetings to enable focused discussion on each of the domains for onward assurance to the Board via the integrated board report and other regular reporting to board committees. 2015/271 11:23 Friends and family test The monthly report was received and noted. The Trust was meeting all of its targets and out-performing most of its internal stretch targets. In addition, an internal audit review of the Trust s arrangements for PPI (patient and public involvement) had given a significant assurance opinion. Mr O Daly agreed to follow up the response rate issue in the surgical triage unit (STU). 2015/272 11:25 Quality impact assessments The QIA in relation to patient prescriptions in the emergency department was received and noted. A revised process for scrutiny of QIAs would be submitted to the committee 12

12 in January /273 Any other business previously notified to Chair Nil. 2015/274 Evaluation A number of new risks had been identified during the meeting for upward reporting to the Trust Board. 2015/275 Items for future meetings Magnet Hospital presentation Development and oversight of QIAs 2015/276 Items to be brought to the attention of the Trust Board Winter resilience bed capacity and reconfiguration and its relationship to heat in the system The relationship between research staff with honorary NHS contracts and care of patients using NHS services (never event) The TDA infection control re-visit Junior doctors strike 2015/277 11:30 Date and Time of Next Meeting The next meeting would be held on 16 December The meeting closed at 11:30. 13