Agenda Item 3a
Quality Committee
Minutes of the Milton Keynes Hospital NHS Foundation Trust Quality Committee
held at 14:00 hours on 26 March 2014 in Room 6, Post Graduate Centre, at Milton
Keynes Hospital
Chair:
Kate Robinson (KR)
Members:
Jean-Jacques De Gorter (JDe)Ann Dring (AD)
Lisa Knight (LK)
Chris Mellor (CM)
Jane Naish (JN)
Julie Orr (JO)
Adrienne Rutter (AR)
Matthew Sandham (MS)
Martin Wetherill (MW)
Tina Worth (TW)
-
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Non Executive Director
Non Executive Director
AHP Core Clinical Division
Director of Patient Care
Trust Chairman
Deputy Chief Nurse
Head of Nursing (Medicine)
Public Governor
Head of Nursing (Surgery)
Medical Director
Risk Manager
Present:
IN ATTENDANCE:
Carol Duffy (CD)
Michelle Evans-Riches (MER)
Dr Rabinder Randhawa (RR)
Assistant Trust Secretary
Trust Secretary
Consultant Respiratory Physician (item 6)
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Agenda Item 3a
1
Welcome, Introductions and Apologies for Absence
KR welcomed JDe, who was recently appointed as a Non-Executive Director to his first
meeting and round table introductions of those present was given.
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Apologies were received from Penny Emerson, Kate Faulkner and Joe Harrison
Declarations of Interest
There were none received.
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(a)
Minutes and Matters Arising from previous meetings
Minutes of the meeting held on 26 February were reported.
Resolved: That the minutes of the meeting held on 26 February 2014 be agreed as a
correct record.
(b)
Matters Arising and Action
Action 265: Dissemination of Learning
A report was to be received at the Board of Directors Meeting.
Action 272: Quality Safety and Performance report
TW reported on ongoing work to improve the information reported to the Committee to
provide assurance
Resolved: That the action log as updated at the meeting be received and accepted.
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Directors report
LK reported on the following items:Based on the outcome of the CQC intelligence report, work was now being undertaken on
CQC visit preparedness. A draft schedule had been formulated with Executive Director
leads for each workstream. There will be a team working across multiple themes, examining
risks and gathering and collating evidence and peer review would also to be incorporated.
Interviews were currently taking place for a Governance Lead and LK stated that more
information would be available for the next meeting.
Action 306: Lisa Knight
LK confirmed that a meeting had taken place between LK, MER and TW regarding the
association of the Quality Board and Quality Committee and a proposal pertaining to the
Quality Board terms of reference was being presented to the Chief Executive, Joe Harrison.
LK confirmed that she would report the outcome back to the Quality Committee when it was
available.
LK reported that as the result of a nomination by a mother, Tracey Rea, Bereavement
Midwife had received a ‘Tommy’s Healthcare Hero’ award. There was a video available for
viewing.
Governance and Risk
MW reported that Jill Hall, Interim Head of Governance was overseeing the review of
governance and risk mechanisms which play an important part of the CQC inspections. MW
confirmed that a report looking at all areas of governance and risk registers across the
organisation covering such areas as financial and corporate governance was being prepared.
MW stated that Bob Green Chairman of the Audit Committee had been appointed as the NED
lead for this work.
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Agenda Item 3a
Resolved: 1. That the Directors report was received and accepted.
2. That a vote of congratulations from the Quality Committee be conveyed to
Tracey and recorded for this fantastic achievement.
5
Safety of Hospital out of hours – scope of work
KR stated that although this item had been withdrawn from this meeting’s agenda, the topic
would return to the committee in due course.
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Mortality and Morbidity Meetings Assurance from Divisions - Presentation
KR welcomed Dr Rabinder Randhawa, Consultant Respiratory Physician, Medicine CSU, who
provided the Mortality and Morbidity (M&M) presentation requested by the Committee.
The following key points were highlighted by Dr Randhawa’s presentation:Prior to February 2014, some Medicine M&M reviews had been shared at monthly Medicine
audit half day sessions however these were not evidenced.
Since then serious incidents had been catalogued and looked at across the department to
challenge and provide learning. A standardised process across Medicine Division was being
rolled out.
It was felt that the best place for this to happen would be at the M&M (Mortality & Morbidity
meetings).
The Cardiology team have regular meetings and their actions were also fed back to M & M
meetings.
The vision for the department was that demonstrable progress had been made to reducing
avoidable deaths in the hospital, Keogh’s ambition 1.
In March 2014 at the Mortality Review Group, it was agreed that the Trust wide approach
would follow this example ensuring the Trust has a standardised escalation and deescalation method for recorded actions and identified shared learning.
Trust wide documented and dissemination process was agreed.
Trust wide M & M groups to follow agreed process to ensure effective shared learning which
was evidenced.
Terms of reference were to be developed for all M&M groups.
KR requested that a copy of the structure chart, standard templates and flow charts be received
by the Quality Committee.
Action307: Martin Wetherill
In response to a question from JDe, RR stated that the definition of an unexpected death was
not defined specifically, but if the team thought the death was unexpected or if the death was
not associated with the original presentation, it would be reviewed.
JO welcomed the standardised process.
In response to a question from KR regarding divisional managers meetings, MS confirmed that
each CSU Clinical Director met with the Divisional triumvirate and M&M was discussed.
KR thanked Dr Randhawa for the very helpful presentation.
Resolved: That the Mortality and Morbidity Meetings Assurance from Divisions –
Presentation be received.
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Agenda Item 3a
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Presentation on CQC Intelligent Monitoring Report
LK provided a presentation with regard to the CQC Intelligent Monitoring Report, which was
received in March 2014.
The Intelligent Monitoring Report was compiled by the CQC collating multiple sources of
quality and operational data used to help decide the risk bandings for Trusts. This
information was used to decide whether to undertake an inspection.
There were 180 individual indicators – each indicator was defined as being, no risk, risk (1
point) or elevated risk (2 points) in a certain period of time.
The Trust received 6 points against elevated risks for the: Proportion of patients risk assessed for Venous Thromboembolism (VTE),
 Inpatient survey Q23 “Did you get enough help from staff to eat your meals?” (score
out of 10)
 monitor – Governance risk rating total for elevated risk was 6 points
The Trust received a total of 5 points with regard to: Composite indicator: in-hospital mortality – Haematological conditions
 Inpatient Survey 2012 Q34 “Did you find someone on the hospital staff to talk to about
your worries and fears?” (Score out of 10)
 Inpatient Survey 2012 Q25 “Did you have confidence and trust in the doctors treating
you?” (Score out of 10)
 Composite indicator: A&E waiting times more than 4 hours
 Ratio of the total number of days delay in transfer from hospital to the total number of
occupied beds
The points were then collated and then divided on 180 indicators, therefore for Milton Keynes
11/180 = 6.1% putting Milton Keynes in Band 2.
The Band ratings were (the lower the score the higher the risk):Band 1 : 7.0% Band 2 : 5.5% Band 3: 4.5% Band 5 : 2.5% Band 6 : 2.5%
Going forward LK stated the following:
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That the Trust now had greater understanding of the metrics which the intelligence
report was based on
An assessment against each indicators was being undertaken to identify risks for the
Trust
Opened a dialogue with the CQC about the data
Expecting some improvements from recent surveys
Preparing for a visit, which was likely to be in the summer.
In response to a question from KR, LK confirmed that information would be communicated
across the Trust.
Action 308: Lisa Knight
In response to a question from JDe regarding data captured, MW clarified that in the past there
had been disparity between the Trusts paper and electronic systems, CQC’s system is
electronic and MW reported that work was being undertaken to ensure that the electronic
system was correctly populated, with the facility to track items and actions.
In response to a question from JDe, LK confirmed that CQC preparedness included 5 work
streams with leads reporting direct to the Management Board.
CM arrived
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Agenda Item 3a
Resolved: That the CQC Intelligent Monitoring presentation be received
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Supervisor of Midwives Report
LK reported on the Local Supervising Authority (LSA) Supervisors of Midwives audit that was
undertaken on 21 March 2013, The LSA audit examines five national standards which were
based in the midwives Rules and Standards.
LK highlighted the following key points:These rules and standards were produced by the Nursing and Midwifery Council (NMC).
The report was received by the Trust at the end of November 2013.
The Trust ratio of 1:14(Supervisor: Midwife), caseloads range from 12-15 meets the NMC
requirements.
The supervisory team had met in full 41 of the 49 standards identified and 8 were met in
part. For each of those met only in part the supervisory team had produced an action plan.
There were no standards defined as not met.
An action plan following the LSA audit recommendations was circulated, as requested by the
Management Board, which was also to be presented at the Board of Directors meeting on 2
April 2014. LK stated that the subsequent audit had since taken place and a timely report for
this had been requested.
In response to a question from JDe, LK confirmed that Nursing re-validation and guidance was
still awaited.
In response to a request from JDe, a list of statutory reports for the Trust Board will be
circulated.
Action 309: Michelle Evans-Riches
Resolved: That the Supervisors of Midwives Report and action plan be received.
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Picker Inpatient Survey
LK presented the Picker Survey which was undertaken by the Picker Institute Europe,
highlighting the following key points:The adult in patient survey was mandatory and used by the CQC for hospital ratings
The survey showed that there were many positive aspects of the patient experience and
patients were highly appreciative of the care they receive.
There were 3 outcome themes that required improvement : o Noise at night
o Communication
o Discharge Pathway
Work was already underway, with (reduce) noise at night campaign, communication
campaign especially focussing on ‘Hello my name is....’ and the Discharge pathway.
A presentation by Picker has also been made to the Trust Board, Management Board and
Clinical Board.
LK reported that the Management Board had tasked ownership of the data to the Quality Board
and the action plan was to be brought to the Quality Committee.
In response to a question from JDe, JN stated that triangulation of data such as the Friends &
Family Test and comments from the noise at night survey confirmed the issues that were raised
in the inpatient survey.
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Agenda Item 3a
In response to a question from KR, MW confirmed that Picker had suggested mini reviews
across departments and that the Trust had recently procured ‘I Want Great Care’ will provide
real time feedback on themes.
Resolved That the Picker Inpatient Survey be received.
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Thematic Analysis of Dementia Carer’s audit Q2 and Q3
As part of the Dementia Commissioning for Quality Innovation (CQUIN) monthly carers audits
were carried out, LK reported on the thematic analysis of the responses collated in Quarters 2
and 3 and the associated action plan.
LK highlighted the following key points:The audit focuses on 5 questions
A common theme from the comments for all 5 questions was communication
Positive experiences were received related to the ‘This is Me’ form and wider use was being
encouraged across non clinical areas and nursing homes.
The outcome of the anaylsis had developed the action plan which included the
Management Boards comments.
In response to a question from KR, JN confirmed that excellent feedback had been received
regarding the simulation skills dementia module and the training the HCA’s were undertaking.
In response to a question from JDe, LK confirmed that the focus on training was set prior to the
CQUIN and from April 2014, dementia training was being provided as part of the essential skills
training for nursing staff.
KR concluded by welcoming the action plan to address the issues identified and also stated that
the report had showed evidence of good practice which families and carers mention.
Resolved: That the Thematic Analysis of Dementia Carer’s audit Q2 and Q3 was
received and accepted.
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Annual Work plan
The Annual Work Plan was presented by MER.
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(a)
Resolved: That the Annual Work Plan be received and approved.
Any other Business
Health Protection Agency review of CDif Terms of Reference
LK reported that the terms of reference were being followed up with the HPA and a response
was expected imminently.
KR and LK reported back on their recent visit to Addenbrookes which had proven to be very
informative. KR stated that good practice and successful models had been shared: For example
the formation of a task force that had resulted in the reduction of CDif that could be replicated at
Milton Keynes. LK confirmed that a plan was to be presented to the Infection Prevention Control
Committee.
LK reported that formal notification had been received from the Department of Health stating
that the CDIf target for next year was 19. LK also conveyed that was likely that there were to be
changes to the Department of Health guidance relevant to testing and the declaration of cases.
The guidance would be examined in detail stating that irrespective of any process RCA would
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Agenda Item 3a
continue.
(b)
Review of Governance - Withdrawn
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Resolved: That the Health Protection Agency review of Terms of Reference were
received and accepted.
Future Meeting Dates 2014
30 April, 28 May, 25 June, 27 August, 24 September, 29 October 26 November
17 December
The meeting closed at 15.55 hrs.
Carol Duffy
Deputy Trust Secretary
27 March 2014
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