Minutes of the Clinical Governance Committee meeting, 16 ...

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Plymouth Hospitals NHS Trust
Trust Board Summary Report
Date of Board Meeting: 31 October 2008
Name of Report: Clinical Governance Committee Minutes Sept 08
Authors:
Approved by:
Presented by:
Dr Peter Glew, Associate Medical Director for
Clinical Governance
Professor John Bull, Chairman
Professor John Bull, Chairman
Purpose of the Report:
To update the Trust Board on clinical governance issues discussed and
agreed at the 16 th September 2008 Clinical Governance Committee meeting
encompassing the following:
• Fractured Neck of Femur Update – improved August figures of 89%
attributed to additional theatre capacity
• NICE Action Plan for CG47 Febrile illness in Children - issues included
limited junior doctor training, partly due to funding and lack of a release
mechanism
• NICE Implementation Compliance Report - 84% compliance had been
achieved, large number of unknowns against audit to be monitored closely
• NICE Implementation Team Terms of Reference approved
• NSF Implementation Process approved
• NSF Compliance Bi-Annual Report - new lead for Children & Young
People’s NSF and Maternity NSF, improvements in progress were
expected
• Medical Device Training Report - 5 main recommendations discussed and
supported
• New Interventional Procedure – Total Wrist Replacement presented and
approved subject to a business case
• New Interventional Procedure – Transcatheter Aortic Valve Implantation
presented and approval was given for the clinical aspect of the procedure
• CEMACH – update report given, Trust is mainly on target for
recommendations, training issues highlighted
• Review of Incident Reporting System – agreed numbers of incidents in
holding area to be included in the monthly performance reviews
• Policies – Training Needs Analysis, Safeguarding Adults Policy, Clinical
Record Keeping Policy and Report Aggregation Statement were approved
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Action Required:
The Trust Board is asked to note the attached minutes and actions taken.
Recommendations:
None
Relationship with the Assurance Framework (Risks, Controls and
Assurance, Annual Health Check):
Provides an update on clinical governance activities, which directly impact on
Standards for Better Health and Annual Health Check.
Summary of Financial & Legal Implications:
None
Equality & Diversity and Public and Patient Involvement Implications
Both equality & diversity and patient & public involvement are well
represented on the Clinical Governance Steering Group, which reports
through the Clinical Governance Committee.
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Item 10
Plymouth Hospitals NHS Trust
Clinical Governance Committee
Tuesday 16 th September 2008 at 12.00 – 14.00
Cardiac Meeting Room Level 9
Draft Minutes
Present: Professor John Bull (JB) Chairman
Tony Beecher (TB) Non Executive Director
Craig Bibby (CB) Risk Manager
Peter Glew (PG) Associate Medical Director for Clinical
Governance
Jayne Glynn (JG) Clinical Governance Support Manager
Madeleine Jephcott (MJ) Deputy Director of Professional Practice
Alex Mayor (AM) Medical Director (Professional Practice)
Paul Roberts (PR) Chief Executive
In
Attendance:
Kerri West
Helmy Fekry (HF)
Susan Loxdale (SL)
Rachel Howells (RH)
Victoria Daley (VD)
Andy Nevill (AN)
Ian Cox (IC)
Sarah Fitzpatrick (SF)
Anne Bussell (AB)
Minutes
Consultant Orthopaedic Surgeon
Consultant Anaesthetist
Consultant Paediatrician
Educ. Development Pract. Equip. &
Governance
Director of Healthcare Science &
Technology
Consultant Cardiologist
Clinical Risk Manager Maternity
Head of Clinical Records & Knowledge
Services
1. Apologies
Apologies were received from Louise Hardy, Peter Jenks, Angela Lamb,
David Edwards and Matt Prior.
Action
2. Minutes and Matters Arising
Minutes of the last meeting were agreed as a true and accurate record. The
Committee were asked to note that unfortunately due to a change in
administrative support a fully comprehensive set of minutes were unavailable.
3. Review of Actions
JB took the Committee through a review of the action table.
4. Briefing from the Associate Medical Director for Clinical Governance
4.1 Fractured Neck of Femur Update
Helmy Fekry briefly outlined the Fractured Neck of Femur Pathway and
handed over to Sue Loxdale who gave a presentation detailing the current
position. SL explained there are three quality Indicators:- Post-Operative
Length of stay, Length of Stay and Readmissions. The current length of stay
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timescale of eight days was considered to be unrealistic.
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Benchmark evidence had been gathered from ‘Warwick University Length of
Stay Hospital Episodes Statistics for 2005/6’, two categories were considered
‘spells’ and ‘super spells’. Spells were explained as admission until medically
discharged which on average was 15 days and super spells which included
rehabilitation and community care on average was 21 days. Difficulties
gathering performance data sets was highlighted, it was agreed PG would
write to Paul Cooper highlighting the current difficulties with data collection for
Orthopaedics and ask him to work with the directorate to find a solution.
PG
Recent changes have improved the FNoF Pathway including:
• Pre-op echocardiograms; which have significantly reduced time to theatre
delays, the portable machines has meant there are no longer cancellations
due to no echocardiogram
• Changes to the Anticoagulation (Clopidogrel) Policy have the eliminated
the need for 5 day wait
• Orthogeriatrician appointment
HF pointed out that shortening pre-operative stay reduced the length of stay
post-operatively. Consideration was given to allocating the first two slots on
theatre lists to FNoF, SL felt there was no spare capacity on current lists and
therefore suggested a stand alone list. Consideration was given to the
practicalities of running the fracture neck of femur service.
August figures for treatment within 48 hours improved to 89%, a huge
improvement on the average 50-60%, this was attributed to additional
capacity in elective theatres. HF felt there was still room for improvement
particularly with additional theatre capacity. AM pointed out fit to discharge
was different to actual discharge due to availability of community care.
The current 13% mortality rate was considered too high and SL was in the
process of examining the relevant notes in more detail to ascertain why.
SL and HF were commended for identifying problems with the FNoF pathway
and highlighting solutions, and felt it was clear the limiting factor was theatre
capacity. HF suggested running two further trauma lists which would reduce
the total length of stay by 2/3 days and provide an overall increase in theatre
capacity. AM highlighted the theatre efficiency work being undertaken by
Richard Best and suggested contacting him for further advice.
It was agreed SL and HF would present their report along with a business
plan to the next Quality & Safety Board meeting scheduled for 6 th October.
AM felt the issues raised should be considered as a community and
suggested forming a Darzi Group to discuss unplanned care. It was agreed
James Palmer and AM would facilitate the formation of such a group, AM
offered to contact Peter Rowe, PEC Chair.
SL/HF
JP/AM
/SL/HF
At TB request it was agreed the Committee would continue to receive the
FNoF data on a regular basis.
SL and HF were thanked for their presentation.
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5. Clinical Risk
5.1 Action Plan for CG47 Febrile Illness in Children
Rachel Howells presented the action plan for Febrile Illness in Children, Nice
Guidance CG47. She explained that in order to assess children who present
with fever a traffic light system had been developed, which would help
distinguish the differences between poorly and the ‘few’ very poorly patients.
Junior doctor training has been identified as an issue, 75 doctors require
training and to date approximately 15-20% had undertake the course. In
addition a Kids Guide had been produced, although this was useful it was felt
this would not address interactive skills training.
JB asked what level of compliance had been achieved by the Trust. RH
confirmed the only area not addressed was training, funding issues and a
release mechanism were required, although release time had been
incorporated into job plans it remained a challenge.
AM suggested involving the Deanery who he felt should have some
responsibility particularly if duplication of training was to be avoided. The
Committee asked for assurance that training would be in place. AM queried
whether training would be included as part of the F1 and F2 programme, PH
confirmed it was for paediatrics. PDR pointed out the Paediatric
Assessment Unit move adjacent to Paediatric A&E would improve the current
situation.
RH was thanked for her presentation.
5.2 Clinical Incident Quarterly Monitoring Report –Apr to Jun 08
PG presented the Clinical Incident Monitoring Report and explained part 1
gave an overview and part 2 provided directorate specific information. The
Committee felt the report was much improved and provided useful
information.
JB highlighted the decline in clinical Incidents reporting and asked CB
whether this was an accurate reflection. CB felt the focus of incidents had
now changed and confirmed the figures had reduced by 1000 per annum. MJ
queried whether reporting staff shortages was an appropriate use of the
clinical incident monitoring system. CB pointed out there was a risk that
patient care could be compromised when staffing levels were low. Following
consideration it was agreed that in the absence of an adverse incident all staff
shortages should be reported through the On Call Manager.
Item 10
PG stated that incidents must be managed with staff feedback. AM
emphasised the importance of full engagement with directorates, there have
been failures to understand when to report, importance of processing
information at directorate level and how to use the data supplied. AM
suggested asking Chris Hall, who was currently dealing with issues relating to
the risk register, to help with improving the clinical incident reporting process.
CB
5.3 NICE Implementation Quarterly Compliance Report Jun 08
PG presented the NICE Implementation Compliance Report stating 84%
compliance had been achieved. Work with the PCT continued for those
pieces of guidance which covered both primary and secondary care.
JB noted the high number of ‘unknowns’ recorded at the audit stage, PG
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ecognised some areas were weak when providing audit information, this
would be closely monitored in the future. Overall PG was pleased with the
response rate for compliance.
5.4 NICE Implementation Team – Revised Terms of Reference for approval.
PG presented the terms of reference for approval, explaining they would be
responsible for monitoring the NIT process and not monitoring compliance.
The Committee agreed the terms of reference.
5.5 NSF Implementation. Revised Process for Approval
PG presented the process document and confirmed no further comments had
been received. JB noted the flow chart was still missing one or two roles, PG
confirmed this would be resolved shortly.
The process was approved.
5.6 NSF Compliance Bi-Annual Report
PG presented the report and highlighted the table at the back of the
document. Some difficulties had been experienced with the Children and
Young People’s NSF, however a new lead had been established and was
moving things forward, this also applied for the Maternity NSF. The Mental
Health NSF Lead was away on maternity leave, and a replacement lead was
covering, this has led to some delays.
It was noted the risk register would be updated to reflect these issues.
6. Medical Device Training & Competencies Update
VD presented the update report and explained that in preparation for the
pending NHSLA Level 2 assessment PG had asked Jacqui Connell and Andy
Nevill to undertake a review of C4b. In July 2008 the Healthcare Commission
visited the Trust and examined specific core standards including evidence for
standard C4b, which included a litmus test focusing specifically on infusion
devices training. The Trust is expecting a NHSLA assessment against level 1
and 2 in December 2008.
The Medical Device Training Policy is due to be presented at the Clinical
Governance Steering Group in October. The review produced five main
recommendations three of which were linked to the asset register:
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• Approval of the Medical Device Training Policy
• Ensure Medical Device Link Practitioners have protected time to carry out
their role
• CGC to support work looking at the asset register, risk register, local
training needs analysis, incident reports and to centre training where
required the most. When asked by JB who would undertake the work, AN
confirmed the Central Training Department have implemented a short term
project ‘Utilisation of Medical Devices’. Initially the asset register would be
established, once in place a team would visit the wards over 3/4 months
validating the information held. JB asked if keeping this up to date would
prove a problem, a procurement link was required if this was to be
maintained. JB asked PG to monitor progress and ensure the project
stayed on track.
• Directorates to ensure good procedures are in place for training and staff
competence records; good evidence was required across the board for
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NHSLA. It was noted AT Learning would be critical in achieving this
recommendation and compliance for C4b. PDR asked whether AT
Learning would include doctors and when the expected roll date out would
be. PDR went on question the suitability of the AT Learning for the
Hygiene Code.
• Support the prompt roll out of the record management system to support
medical device training and competency
The Committee supported the recommendation and emphasised the need to
deliver within a set timeframe. PDR suggested wider work on some
governance issues, continue to audit compliance.
7. New Interventional Procedures
7.1 Total Wrist Replacement
Charles Gozzard presented the Total Wrist Replacement procedure,
explaining this would be used for rheumatoid arthritic patients as an
alternative to total wrist fusion. The benefit of this procedure was improved
functionality and pain relief, however the uncertain long-term outcome was
noted.
NICE recently issued guidance stating this as an alternative option and
agreed there were benefits however reiterated the limited outcome
knowledge, therefore the need for careful auditing was imperative. CG
emphasised the importance of making patients fully aware of the risks
including the potential for dislocation and loosening of the prosthesis. Patients
must also be aware that if there is a problem they may then require total
fusion.
CG and Sue Fullilove intend to operate together with a company
representative until the technique is perfected. Workshops are available in
2009 and they are keen to attend. If approved the first procedure will take
place in the near future and CG confirmed they have identified a suitable
patient.
NIPS paperwork had been originally submitted in July; however the risk
assessment was not ready at that time. The Committee highlighted the need
for a full business case and CG confirmed Keith Chapman was taking this
forward.
Patient information leaflet had been produced by CG and a NICE leaflet was
available, CG confirmed he expected to perform approximately 6-7
procedures a year. JB what audit plans were in place, CG explained NICE
have produced a printed document for audit, with outcome scores sent to
National Joint Registry. JB reiterated the importance of benchmarking.
JB concluded that subject to a business case the Committee agreed for the
new procedures to proceed as the benefit to the patient is clear.
7.2 Day Case Tonsillectomy
Matt Prior was unable to present at the meeting due to illness. PG
summarised the basic audit which showed the procedure presented no
additional risk to the patients. JB noted the haemorrhage figures. PG
confirmed this procedure would be limited by the day case rules (bridge
restrictions).
Item 10
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Matt Prior would be asked to complete the new interventional procedure
paperwork and present to the November meeting.
7.3 Transcatheter Aortic Valve Implantation (TAVI)
Dr Ian Cox presented the report and explained he would like to set up a
tertiary service using the new technology. The procedure allowed valve
replacement without open heart surgery, this procedure would mainly benefit
frail patients.
IC estimated that 30-40 patients per year would be treated. NICE states that
a multi disciplinary selection process must take place for each patient, a
devil’s advocate member must be including in the process.
Training has been undertaken and visits to six other units to view cases had
taken place. PG pointed out the procedure had been discussed fully and the
new interventional paperwork was expected shortly. JB emphasised the
importance of producing a business and gaining commissioner approval.
The Committee gave approval for the clinical aspect of the procedure.
8. Confidentiality Enquiry Maternity & Child Health Bi-Annual Update
Report
Sarah Fitzpatrick presented the CEMACH report and informed the Committee
that the Trust was on target with the recommendations. The directorate were
working through the report chapter by chapter, gap analysis and action
planning have been completed up to chapter 8.
SF stated that all obstetric staff require training including clinicians, junior
midwives and health care assistants, ten courses per year are available with
forty places on each course. It was noted there was some difficulty achieving
100% attendance and backfill for staff would be required in order to release
individuals for training, particularly for clinicians.
PDR asked whether attendance at training should be included in the appraisal
process. SF went on to explain the difficulties with prioritising training
requirements e.g. midwives were expected to attend thirteen study days per
annum to meet recommended requirements, of which only two are funded.
However it was noted not all of these were mandatory training.
PDR emphasised the need to make evidence based decisions regarding
training requirements.
The Committee thanked SF for her presentation.
9. Review of Incident Reporting System – Including Projected Number of
Incidents
CB presented the report and explained figures showed a projected shortfall
greater than expected. The contributing factors were considered to be:
clinical staff with limited IT skills, access to computers, failure of managers to
manage incidents and lack of feedback. CB and MJ emailed all managers
reiterating the importance of managing their incidents and set a one month
deadline to address the situation, unfortunately at the end of the month the
number of incidents in the holding area had increased.
CB confirmed that 50% of his time was spent delivering training. Support
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user groups do not seem to have improved the situation.
Item 10
It was agreed clinical incident data, including numbers of incidents in the
holding area, would be included in the monthly performance review meetings
organised by Paul Cooper and John Yarnold. PG confirmed directorates
receive monthly data from the Clinical Risk Team. MJ agreed to approach
matrons in an effort to raise awareness and improve the situation. JB
emphasised that directorates must be made to take this seriously.
10. Policies
10.1 Training Needs Analysis.
VD presented the Training Needs Analysis. This document collated all
mandatory and statutory training requirements and would be used as a tool
by the training team to develop a training strategy for the delivery of training
programmes. The Statutory / Mandatory Working Group will meet on a biannual
basis and a full analysis and evaluation of the Directory will be
undertaken following the meeting. The Committee approved the Medical
Device Training Policy.
10.2 Safeguarding Adults Policy
MJ explained NHSLA require the Trust to have its own internal policy,
previously the Trust had worked with the PCT. The biggest difficulty was
proving use of the policy. Karen Grimshaw is the Executive Lead for
Safeguarding Adults and Alison Hunt, the Lead Officer. TB highlighted the
directors’ responsibilities.
The Committee approved the Safeguarding Adults Policy.
10.3 Clinical Record Keeping Policy
AB presented the Clinical Record Keeping Policy which had been designed to
replace the old Health Records Policy, it was noted the policy complied with
NHSLA and S4BH. The new policy included how to write in records, outlined
roles and responsibilities within the Trust, the effectiveness of how we track
records, monitoring compliance and effectiveness and included cross
references to APNs (Administrative Procedure Notes).
AB presented the policy to the September CGSG, members were given two
weeks to provide comments. Once the policy is agreed it will be published
and widely distributed through vital signs, series of open days and drop in
sessions to talk about the policies. The Health Records Group plan to
disseminate the information through directorates and oversee the audit of
compliance. It was noted the policy would be enforcing current practice and
providing guidance.
10.4 High Level Enquires
PG presented the policy, which had been produced to illustrate methods for
the implementation of high level enquires, similar to Climbe enquiry, and
included a Gap Analysis Tool. The policy was expected to be a short-life
document, PG planned to combine three policies including: NCEPOD, High
Level Enquiries and Confidential Enquiries. PG emphasised the main issue
when dealing with such an enquiry would be implementing the
recommendations.
TB queried the frequency of such an enquiry, PG replied these reports were
infrequent and confirmed the last enquiries were Climbe and Shipman.
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Item 10
The Committee approved the High Level Enquiry Policy.
10.5 Report Aggregation Statement
PG presented the statement and explained this was an addendum to the
CGSG terms of reference and that aggregation of reports was now a NHSLA
requirement. The Trust are expected to produce an annual aggregated
report, identifying common factors within claims, complaints and clinical and
health & safety incidents. The report would be produced and submitted to the
CGSG and CGC for consideration.
JB asked how the information would be used, PG explained it would
disseminated to each clinical director for review and where applicable action
planning. The trends would be monitored via the quarterly incident reporting
process with progress presented to the CGSG and CGC on subsequent
annual aggregated reports.
11. Items for information
11.1 Clinical Governance Steering Group Minutes 7 July 2008
Explanatory Note - Unfortunately due to a change in secretarial support, full
and comprehensive notes were not available for the September Committee
meeting. The Committee noted the minutes.
11.2 Infection Control Committee Draft Minutes 5 August 2008
The Committee noted the minutes.
11.3 NICE Implementation Team Minutes 22 July 08
The Committee noted the minutes.
12. Any Other Business
There was no other business discussed.
13. Date of Next Meeting
The next meeting is scheduled to place on Tuesday 25 November 2008,
12.00 – 14.00, Cardiac Meeting Room, Level 9.
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