Quality Governance Committee Assurance Report - July 2024
Meeting: Public Meeting
Date: 10 July 2024
Report Title: Quality Governance Committee Assurance Report
Agenda Item: PUB24/07/3.2
Committee Date: 26 June 2024
Meeting Chair: Catherine Glickman – Non-Executive Director
Meeting Quorate: Yes
Purpose: Assurance
Recommendation: The Board is asked to receive assurance from the business discussed at the meeting and to review the matters for escalation and referral.
Link to Strategic Objective:
- Provide outstanding quality of care and performance
Summary of Items Considered at the Meeting
Quality Metrics
Consideration: The Committee reviewed the ACQI metrics and Patient Experience data. For Cardiac Arrest, EEAST’s performance was better than the national average (October 23); on Stroke, the performance was in line; on STEMIs, EEAST’s times were higher than the national average, both on mean and 90th percentile – this had been the subject of a PSIR thematic review.
Resolution/Outcome: The Committee agreed that, together with the Performance and Safety and People Committees, we should agree the metrics that each Committee reviewed as there was felt to be overlap (eg. Volunteers) but other areas were not getting the review they should, specifically Safety. The Committee asked if the patient experience metrics could be presented using the statistic process control (SPC) methodology so trends could be easily identified – to be discussed with the Informatics team.
Assurance: Reasonable
PSIRF – Bi-annual Review
Consideration: The first update to the Committee presented by Liam Dunn, Head of Patient Safety. The paper covered the implementation of PSIRF: it was fully operational with training complete for key roles; weekly reviews were being held, typically three per week. There was a discussion of the three themes emerging to date: Missed STEMIs (report complete), Non-conveyance (due July/August), and PTS injury (at information collation stage).
Resolution/Outcome: The Committee recognised the work to implement PSIRF effectively. It also recognised that the 40 Structured Judgment Reviews had been completed for the last 2-months, although this was not shown in the pack. The Committee asked that the Missed STEMI report be circulated so that it could see how the report was structured and its conclusions. The Committee discussed receiving the thematic reports and discussing the key points as part of the quality agenda. The Committee also noted the definition of PSIR Harm level, which would increase the number of fatalities recorded, ie. actions ‘may have contributed towards’ rather than ‘did’. The Committee took confidence from the way the PSIRF had been implemented, this was a good first update and it should continue to agenda this as PSIRF embedded.
Assurance: Substantial
Patient Experience
Consideration: Rachel Morris, Head of Patient Experience, talked through the ways that we collected patient feedback and handled complaints, together with how this was fed-back across EEAST. EEAST was also reviewing communication against the Maturity Matrix and reviewing how we were deploying resources in the team.
Resolution/Outcome: The Committee supported the work undertaken to date and recognised that it was a small team, particularly the Patient and Public Involvement (PPI) team. There was a suggestion that the ICBs and Healthwatch were already collecting a lot of information in their areas, which the team could access, and there may be some funding available to support the desire to increase health equity and diversity in relation to EEAST feedback.
Assurance:
Evolution of Complaints
Consideration: Rachel Morris presented a proposal, which ELT were to work through on 02 July, to evolve the current complaints procedure to track and report on all concerns and complaints, early resolution of complaints or concerns, update staff training to value complaints and how to investigate and set up Complaints Panels. This would mean that EEAST’s provisions were in line with best practice
Resolution/Outcome: The Committee was asked for input, as this was still to be discussed by ELT. The Committee supported the proposal: it was recognised that the numbers would increase, and so would the richness of information and insight. The speed of resolution could also be tracked across all complaints.
Assurance:
Independent Review: Frequent Ambulance User
Consideration: Simon Chase provided an update on the action plan resulting from the independent review and its progress – a further review will be provided to the Committee
Resolution/Outcome: The Committee recognised the work undertaken to date but questioned the timescales, given the review was completed in April 2023, and that we were not accepting some of the recommendations. Simon Chase explained that there had been changes in the approach more broadly, so some recommendations had been overtaken, and others were difficult to make measurable. The Committee agreed to a further progress check.
Assurance:
Corpuls Software
Consideration: Liam Dunn explained that the Glasgow+ software had been purchased; there had been limited deployment so far and full roll-out should be completed by October 2024.
Resolution/Outcome: The Committee noted that the roll-out had begun, the software added more weight to clinicians declaring a STEMI and therefore a consultant response, but it was too early to say if it was making a difference to the ACQI. The Committee asked for an update for the 25 September meeting on its efficacy.
Assurance: Reasonable
Regulatory Assurance
Consideration: The Committee reviewed and noted the progress against the CQC Quality Improvement Programme.
Resolution/Outcome: The Committee supported the progress made and will continue to monitor progress against the Must Dos and Should Dos.
Assurance: Moderate
Clinical Audit Annual Report 2023-24
Consideration: Natalie Mudge, Head of Compliance, confirmed that the 2023-24 Clinical Audit Plan had been completed in full, the first time in 10 years: strengths were clinical outcomes; more work to be done on complete documentation. An Internal Audit had confirmed Substantial Assurance.
Resolution/Outcome: The Committee congratulated the team on completing the full audit programme and achieving a strong independent endorsement through Internal Audit. The Committee approved the Report for publication and supported the reduction in the risk rating from 12 to 4
Assurance: Substantive
Board Assurance Framework
Consideration: The residual risks remain high.
Resolution/Outcome: The Committee supported the conclusions of the paper: the risk register was being updated to reduce the risk for medical devices given the annual report and ISO standard achievement. The Committee also agreed that a Board review of Advanced Practitioners would be valuable, as it crossed Committee remits
Assurance: Reasonable
Sub-Group Assurance Report
Consideration: The Committee reviewed the report.
Resolution/Outcome: Groups were meeting regularly with good attendance and providing assurance of progress.
Assurance: Reasonable
Matters for escalation or referral
Busy agenda, resulting in areas not being discussed or at a high level
To: N/A
Reason: It was agreed that we should focus on specific topics, particularly on areas of risk, across the annual meeting cycle.
Community First Responders: reporting through KPIs on hours used and how more hours could be deployed
To: People Committee
Reason: Volunteer hours used are around 10 to 15% of the available hours: this is due to a mix of geographical spread, capability and availability. The Committee asked if we could increase volunteer deployment to support improvement in response times.
Patient Transport Service (PTS) issues
To: Performance and Safety Committee
Reason: The Committee discussed whether the PTS cancellations or late arrivals were contributing to deterioration over time of long-term health and therefore quality of care?
Better communication to patients for non-conveyance rationale
To: Performance & Safety Committee
Reason: A source of patient complaints was that they felt alternative pathways were not appropriate for their case. This reaction may be aggravated by the way it is explained to them – could the communication be better tailored to explain why a different pathway was better for the patient?
