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Microsoft word - qc summary of assurances risks for trust board 06 01 1
Summary of Assurances & Risks
from Committee Meetings
Name of Group:
Date of meeting:
Key issues arising:
Board approval to roll out e-PRF to remainder of Trust;
Manchester patient safety culture review;
Community working through Know Your Blood Pressure campaign, to include funding from the British Heart Foundation;
Senior manager from outside the Trust working 2 days per week on the implementation of the safeguarding review action plan;
Replacement of Category C with 11 clinical indicators;
Work with South of Tyne Commissioners to provide triage to alternative care pathways for care homes;
Reporting and terminology of SUI’s to SI’s;
All grades 1 & 2 SI’s to be reported in the Annual report.
Formation of a sub group to tackle statutory and mandatory
training non-compliance and safeguarding training.
Invitation to operational reps to attend Medicines Management group.
Key areas of assurance:
Resolution to the issue of vulnerable patient forms being
CQC Compliance – directors signature required for sign off;
HPC will advise Trusts of paramedic registration lapses;
All staff have completed Stat & Man training for the period 2009-10;
Submission of Annual Cycle of Business and Terms of Reference by sub groups;
CIP quality methodology developing well (a member of the Clinical team is involved in the review of the clinical gateways to provide assurances that clinical issues are not overlooked);
Complainants whose grievance was ‘part upheld’ still received a full response as part of the Trust’s ‘Being Open’ policy;
Management of the Pathways 10 minute call back time;
Review of the Clinical Directors Risk Register at each meeting;
Submission and approval of QSSD policies relating to the directorate;
Instigation of hard copy CPC on stations.
Key risks identified:
Number of paramedics trained in child safeguarding;
‘Real time’ delay in crews submitting vulnerable patient forms;
Lack of attendance at Stat & Man training (2010-11) will prevent 100% completion;
Clarity is still awaited with regards to the drugs which will be stocked on the NCMCEV vehicles;
Strength of morphine to be stocked on the emergency planning vehicles differs from that currently in general use;
Reluctance by staff to complete online safeguarding training in allocated abstraction time;
Items for escalation:
Safeguarding Training and Statutory & Mandatory training risks
to be raised at Workforce and Equality Committee meeting.
Number of apologies:
Number and details of
outstanding actions from
MINUTES OF MEETING
06 January 2011 at 0930hrs, Boardroom, NEAS HQ
Mr P Wood, Non Executive Director (Chairman)
Mr G Campbell, CGC A&E Ops Representative (North Durham)
Mr D Abbs, CGC A&E Ops/Rapid Response Representative (Durham) Mr M Cotton, Assistant Director of Communications & Engagement Mr S Carr, CGC PTS Representative (South Tyne) Mrs T Cook, Clinical Practice Manager Mrs J Cowen, Head of Workforce Development Mr T Dell, Chairman Miss J Duckett, Projects Officer Mr P Fell, Head of Clinical Care & Patient Safety Mr A Gallagher, Head of Risk & Claims Mr K Han, Medical Director Ms C Jobling, Clinical Supervisor, Team Leader Mr M McDougall, Operations Manager Dr S McLure, Research and Development Manager Mr S Potts, A&E Operational Representative (North Tyne) Ms D Ridley, Programme Manager Mr A Rubbi, CGC A&E Operational Representative (South Tyne) Mrs P Russell, Pharmacy Advisor
Mrs G Summers, Complaints Officer Ms L Thirlwell, Safeguarding Officer Mr M Willis, Head of Clinical Education & Development
Miss B Halpin, HR Policy & Planning Manager
Miss H Scales, Monitoring & Compliance Officer
Mrs P Holder, PA to Director of Clinical Care & Patient Safety, and Medical Director
The Chair of the meeting updated the group on progress towards FT status. He stated that
the role of this Committee in terms of achieving our goal was key.
APOLOGIES FOR ABSENCE
Apologies were received from the following:
Mr T Birdsey, Assistant Ops Manager (North Tyne) Ms L Crawley, Human Resources Manager Mr A Davison, Team Leader, Stanley Station Mrs A Fox, Director of Clinical Care & Patient Safety Mr S Featherstone, Chief Executive Mr D Hewitt, CGC A&E Operational Representative (North Tyne) Mr D Haworth, CGC A&E Operational Representative (Tees) Mr T Langley, Operations Manager, North of Tyne Mrs C McManus, Infection Prevention and Control Manager Mr P Richmond, CGC A&E Operational Representative (South Durham) Mrs D Teasdale, Trust Secretary Mrs H Tucker, Non-Executive Director (Vice Chair)
MINUTES OF THE LAST MEETING
The minutes of the last meeting held on 04 November 2010 were reviewed and accepted as a
true and accurate record of the business undertaken.
REGISTER OF DECISIONS
The Register of Outstanding Actions was updated and will be circulated with the minutes of
PATIENT SAFETY WEEK – REPORT ON BENEFITS
The report presented outlined that this is the second year that Patient Safety Week has been
held, and whilst a shortage of national supporting literature was noted Mr Cotton felt the campaign was successful. Mr Gallagher is expecting an increase in reporting due to operational staff being made more aware. Members were reminded that to achieve success in regards to Foundation Trust (FT) status, the ability to demonstrate measuring and monitoring will be required as part of the due diligence process.
Reference was made to the new integrated ECLIPs report which may illustrate the potential
impact of the campaign. (Report to be circulated with the minutes of this Committee.)
KNOW YOUR BLOOD PRESSURE CAMPAIGN – UPDATE
The clinical guidelines paper was e-circulated to members prior to the meeting. It was
reported that liaison between Communications, Training and First Responders had taken place where agreement was reached to develop a programme of events around FT membership. Potential funding for the programme through the British Heart Foundation for use at county shows was mentioned and this was also noted to be an example of community action.
SUMMARY OF ASSURANCES
7.i. ECLIPS MINUTES
Meeting to take place on 07 January 2011, minutes from which will be presented at the
In providing an update Ms Thirlwell noted that the issue regarding faxing of vulnerable patient
details has been resolved and all details are now received via the designated mail box facility. Members took assurance that there have been no late safeguarding referrals since the implementation of this practice.
The Safeguarding Lead attended 8 child death reviews in the period November/December
2010 and whilst there were no implications/criticism for NEAS, and concern was noted that 5 of the 6 NEAS staff in attendance at these cases had not received child safeguarding training. This is a recognised area of risk for the Trust and needs to be addressed.
An overall increase in the numbers of referrals received was noted. It was also noted that
although the timeliness of receipt of referrals has improved as outlined above, crews were still unable to make immediate referrals as the referral process can only be undertaken once they arrive back at station. It is anticipated that the Safeguarding review will address this issue.
EXTERNAL REVIEW OF SAFEGUARDING
An independent Internal Safeguarding Review is nearing completion, Trust Directors will be
informed of the content of the findings prior to it being presented at the March meeting.
To assist in the implementation of the Safeguarding Review action plan a senior manager
from an acute trust will be spending 2 days per week in the Clinical directorate as part of a personal development project.
MANCHESTER PATIENT SAFETY CULTURE REVIEW - UPDATE
As part of the above review a business case was presented at ET; Mr Fell will contact all
divisions to seek involvement. A report will be submitted to the Board, and the Trust will act on the recommendations.
SUMMARY OF ASSURANCES
Minutes of the Infection, Prevention & Control Group
The above meeting was cancelled due to elevation of REAP activity.
11.ii. Minutes of the Medical Devices Working Group
11.iii. Minutes of the Medicines Management Group
Clarity is still awaited with regard to the drugs and dosages which will be stocked on
the NCMCEV vehicle. As this could result in multiple doses of morphine being held in the organisation, this was highlighted as a potential risk. It was noted that the drugs Ketamine and Midazolam will be stocked for administration by Doctors only.
In reviewing the listed risks, Ms Russell noted that David Whitmore of the HPC will
advise Trusts of paramedic registration lapses. In regard to the ‘dooping’ of drugs, the difficulties were acknowledged, however a witnessing signature still needs to be recorded. The identified risk of the potential theft of non CD drugs will be reviewed at the next Medicines Management meeting and reported back to the Quality Committee.
Mr Han advised that the use of the drugs Misoprostol and Syntometrine will be
reviewed at the next Clinical Advisory Group.
Mr Willis reported that the department has been quiet due to the recent adverse weather
conditions. A review of paramedic education is taking place in respect of cost and clinical objectives. Funding has been identified for both mentorship and preceptorship.
Members received assurance that all staff (with the exception of two on long term sick) have
undertaken Statutory and Mandatory training for 2009/10. In response to the table of figures
indicating YTD A&E and PTS clinical skills updates Mr Willis was requested to ensure a forecast outturn is included in future reports. Whilst it was acknowledged that abstractions had been factored in to allow training to take place, issues with attendance are still preventing 100% compliance with training requirements. Mr Willis reported that managers are informed of those staff who fail to attend.
Mr Willis was unable to give a precise figure for the number of First Responders trained and
provide evidence of their impact on winter pressures.
The Trust’s Chairman acknowledged that Stat & Man training targets will not be achieved by
the end of March 2011 and enquired as to the consequences. It was noted that the Trust has a legal obligation to ensure compliance and a criminal conviction or imprisonment implications could arise. Operational members of the Committee added that staff were not aware of the potential legal implications arising. The Committee Chair requested that a Sub Group be formed to take this matter and issues of safeguarding training forward to find resolution. Sub Group members will be identified out with the meeting.
Whilst safeguarding training is an online module for completion in abstraction time, Mr Willis
noted staff reluctance to complete the modules. He also cited the lack of Control and HQ staff undertaking the training and noted this was a requirement of any organisation employing staff under the age of 19 years. Mrs Cowen was tasked with raising the concern at the Workforce Development meeting.
SUMMARY OF ASSURANCE
Minutes of the Clinical Education Steering Group
Members were advised that the Clinical Education Steering Group had taken place on
16 December 2010, since the minutes were not available at the time of writing the
report the Chair requested the minutes be circulated with the Quality Committee minutes.
NEAS QUALITY VIEW REPORT
This report was e-circulated prior to the meeting and was developed by Mr Han and Mrs Fox.
It was submitted to the SHA in support of the Trust’s application for FT status. Members
MONITOR QUALITY GOVERNANCE FRAMEWORK – SELF ASSESSMENT
In the absence of Mrs Fox, this item was deferred to the March meeting.
KA34 CATEGORY C AUDIT
Members were informed that from 01 April 2011, Category B classification will cease to exist
and will be replaced by 11 clinical indicators. Clarity on the new indicators is awaited and
once received a report will be submitted to the Committee. Clinical Indicators to form an agenda item at the next meeting.
17.i. Clinical Audit Steering Group
a – Annual Cycle of Business
Members were asked to note the contents of the CASG annual cycle of business 2010-11. A revised plan will be presented in line with National Clinical Performance Indicators for 2011-12.
17.ii. Research & Development Group
a – Terms of Reference
Members reviewed the TOR and subject to the addition of Mrs J Bowler to the membership, approved them.
b – Annual Cycle of Business
Content and detail was noted, and cycle of business approved.
c – Research & Development Strategy
The Committee was requested to review the minor amendments and support the ongoing implementation of the strategy, which they duly did.
d – Research & Development Annual Report
The Committee noted the content of the annual report and the Trust’s Chairman acknowledged the achievement of Dr McLure and her team, adding the work undertaken provides good evidence and a degree of assurance to the Trust. The report was ratified.
17.iii. Medicines Management Group
a – Terms of Reference
The Committee approved the TOR subject to ‘Clinical Governance & Patient Safety’
being replaced with Quality Committee. Mr Fell requested that Operational representatives be invited to attend the meetings.
COST IMPROVEMENT PROGRAMME – ASSURANCES ON QUALITY
The Quality Programme Management Register was reviewed with it being noted that all
projects are analysed for quality/patient safety implications. Mrs Ridley described the modus
operandi of her work to the Committee. The Chair emphasised the importance of this work. This analysis will be complete by the end of January against a framework which reviews all aspects, including value. The Chair commented on the number of red RAG ratings. Mr Fell requested that a member of the Clinical team is involved in the review of the clinical gateways to provide assurances to this Committee that clinical issues are not overlooked.
In updating the Committee Mrs Cook reported that there have been no risks identified,
Pathways 6.2.2. is ready to be tested prior to installation, and will take place when the Trust REAP level reduces. This update introduces the 30 minute disposition code DX015 which also ties in to KA34 changes. In addition, a new question relating to infant bruising has been added in response to a serious untoward incident (SUI). It should be noted that the SUI does not relate to NEAS.
Due to a perceived increase in the number of formal complaints relating to NHS Pathways
Mrs Cook carried out an analysis of complaints in the period, April to November 2010, 43 complaints were received, of which 12 were upheld. These complaints are upheld because
the call taker has taken the wrong pathway, or missed the relevant question from the triage process. It was noted that often complaints may be part upheld as a result of information elicited as part of the investigation but which do not form part of the initial complaint.
It was agreed by the chair of the Quality Committee that G Summers and T Cook would meet
to provide clear definitions relating to the following outcomes to ensure a consistent approach.
This information with be provided at the next Quality and ECLIPS meetings.
111 PATHFINDER PROJECT
20.i. Update Report
Members were advised that the 10 minute call back time is still classed as a risk. This is due to a shortage of staff, interviews are taking place today. Mrs Cook has requested a meeting with DoH and pilot organisation; the Chair took assurances that this issue is being managed.
With regard to the Internal Management of Clinician Calls it was agreed that
Cook and Mrs Jobling will provide a full and comprehensive report for the March
meeting relating to all aspects of the internal management of clinician calls, including data.
20.ii. Business Continuity Plan
This item was deferred due to REAP level and will be presented at the March
999 ALTERNATIVE PATHWAY
NEAS is working with South of Tyne (SoT) Commissioners to provide an alternative care
pathway to strengthen the links between organisations and to relieve pressure on A&E departments by utilising the capacity of urgent care teams and walk in centres.
A significant amount of calls are generated by Nursing Homes in the SoT area; 10 homes are
participating in the initiative to triage calls as outline above. Members received assurance that these calls are audited on a monthly basis as part of the governance procedure.
CLINICAL ISSUES REGISTER
From the period April to November 2010, 153 incidents were reported; of this 133 have been
Members noted the details of the issues outstanding and to provide assurance Mrs Bowler
was requested, in future reports to provide a column outlining interim measure taken against these issues.
The report provided identifies an increase in the number of complaints. This has led to an
increase in the numbers of Reflection & Learning Events taking place. A detailed report will be presented to ECLIPs meeting. The Chair requested details concerning the number of times extensions had to be agreed with complaints. The new Investigating Officer will help in shortening the time frame for investigations.
SERIOUS INCIDENT UPDATE
The report details the changes made to the reporting and terminology of SUIs; these incidents
are now referred to as Serious Incidents (SI) and are categorised as outlined in the paper presented.
Mr Gallagher provided clarity that a ‘never event’ is an incident that should never happen, i.e.
surgical instruments being left in-situ during surgery, as outlined in the paper.
One of the ‘never events’ is allegedly a vehicle not arriving on scene within the agreed
timescale. Mr Cotton raised the implications of this and the fact that the Trust are targeted against a 75 percentile proving difficult to quantify. Mr Gallagher reported that he is attending a national meeting and will feed back.
Mr Gallagher updated the Committee noting cases 1484 and 1496 are expected to be closed
In providing assurance Mr Gallagher noted the Trust has low levels of FOI’s and is regarded
for its good practice and open policy by the SHA/Commissioners.
It was noted that all grade 1 and 2 incidents are required to be reported in the Trust’s Annual
PSP/RPIW PROGRESS REPORT
Mr Fell reported close out and agreement of this process is due next week; the process now
reviews root cause and not only professional standards.
ROOT CAUSE ANALYSIS REFLECTION LEARNING (RLE) REPORT
Members noted that future meetings will include a summary overview of RLE. Since its
inception 23 RLE’s have taken place, 13 have been identified as ‘investigation incomplete’ and 11 have resulted in disciplinary action. Those identified as investigation incomplete were highlighted as a risk.
26.i. Root Cause Analysis Panel Terms of Reference
On reviewing the TOR the Committee gave its approval.
The report submitted provided assurance that evidence will be signed off every 6 months by the appropriate executive; to support this further a random selection will be presented to the Risk & Governance Committee for review. In support of this, members were informed that two policies have been written to assist managers in uploading evidence.
Quality Account – Position Statement for January 2011
The report was received and noted; appendix two identifies that HQ staff are not attending Statutory and Mandatory training in line with requirements; this was identified as a risk. Noting also that IPC2 Vehicle Swabs current status of 98%, members were reassured that vehicles failing swabbing tests are re-cleaned and re-swabbed before becoming operational.
27.iii. Quality Risk Profile
NEAS is scored as ‘low risk’ with an overall score of 2 out of 14, 0 being no risk, 14 being high risk. In benchmarking against similar ambulance trusts NEAS remains in a low risk position. Risk Profile is to become a standing item on the Ambulance Forum agenda, with rating being shared. Members took assurance from the figures stated.
SUMMARY OF ASSURANCES
Minutes of the Clinical Advisory Group Meeting
This meeting was cancelled due to inclement weather conditions and the Trust operating at REAP 3 & 4.
Minutes of the Clinical Audit Steering Group Meeting
Next meeting due to be held on 13 January 2011; minutes to be submitted at the next meeting.
28.iii. Minutes of the Research & Development Group Meeting
Members noted the summary details provided and the risk identified was mitigated. The risk related to the dosage of PILFAST drugs and whether the syringe should be
reused; members took assurance from the memorandum sent to each PILFAST paramedic.
28.iv. Highlight Report from Emergency Care System Project Board (e-PRF)
The verbal update identified that e-PRF has been closed out for the Tees region and a business case submitted to the Trust Board approved to roll out the programme to the whole Trust by 2012.
QLIKVIEW PROGRESS REPORT
An anonymised report was tabled at the meeting providing members with a visual aid. The
reports will provide performance by division on a monthly basis to AoM’s and Team Leaders. This will ensure that Team Leaders are engaged with clinical audit.
In querying the stated figures for ‘onset’ time of stroke, Mr Rubbi advised that data is not
always available to crews; crews were requested to state this within the free text box provided.
The Chair congratulated Miss Duckett and her team on the work thus far, noting the Qlikview
CLINICAL DIRECTORATE RISK REGISTER
Clinical Directorate Risk Register will form a standing item at future meetings; members were
pleased to note that after mitigation there are no amber or red flags and the directorate does not have any risks on the Organisational Risk Register.
BOARD ASSURANCE FRAMEWORK – REVIEW OF ASSURANCES
Due to the absence of Mrs Fox, this item was deferred to the next meeting.
POLICIES AND PROCEDURES FOR RATIFICATION
Items i. to xi., previously e-circulated were reviewed as follows:
QSSD 713 – Obstetric Care – APPROVED
QSSD 712 - Paediatric Care – APPROVED
QSSD 711 – Resuscitation & Recognition of Life Extinct – APPROVED
QSSD 716 – Conveyance of Patients to a Healthcare Facility – APPROVED
QSSD 717 – Clinical Record Keeping – APPROVED
QSSD 718 – Medicines Management – APPROVED
QSSD 1400 – Infection Prevention & Control – APPROVED,
subject to the inclusion
of a sentence advising that Local Involvement Networks (LINKs) is to be replaced Health Watch in the near future.
QSSD 710 – Policy for Patients not Conveyed to Treatment Centre – APPROVED
QSSD 1601 – Research Governance Policy – APPROVED
Procedure for Adding Evidence to CQC Outcomes – APPROVED
Procedure for Cataloguing and Monitoring CQC Evidence – APPROVED
RISKS EMERGING FROM THE BUSINESS TRANSACTED
The Chair identified the following risks
10.iii. - Dosage of Morphine on NCMCEV vehicles
12.- Safeguarding Training 12.- Statutory & Mandatory Training 2010-11 20.- Pathfinder - 10 Minute Call Back 22.- Outstanding Clinical Issues 26. - Root Cause Analysis/Outstanding Investigations
The Chair also highlighted the areas of assurance
10. - Manchester (MAPSAF) Patient Safety Review
17.- R&D Projects 18.- CIP and Quality, clinical involvement 21. - Alternative Pathways 999/Care Homes 27.i. - CQC Compliance Activity 29.- Qlikview Potential 32. - Policy Updates
ANY OTHER BUSINESS
34.i. Clinical Care & Patient Safety Folder
To mitigate the issue of operational staff encountering difficulty in accessing Clinical Practice Circulars (CPC) a folder will be placed on each station containing all CPC and an index. This folder will be regularly updated and CPC’s faxed to stations.
Operational staff appreciated the reasoning behind this initiative and suggested that
folder might also be stored on vehicles to assist when crews are out of their ‘area’. Mr Fell agreed to take this forward for consideration.
DATE & TIME OF THE NEXT MEETING
The next meeting will be held on 10 March 2011, Boardroom, HQ.
REVIEW OF MATTERS DISCUSSED
36.i. Any Contribution to the Cost Improvement Programme?
Item 12 – Education Report – funding for mentor and preceptorship identified.
36.ii. From the Decisions Made, State any Implication
Education Report – formation of a sub group; Mrs Cowen to raise
issues regarding online safeguarding training at the Workforce
Medicines Management TOR – operational staff invited to attend
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