Quality Governance Committee Assurance Report - May 2024
Meeting: Public Meeting
Date: 8 May 2024
Report Title: Quality Governance Committee Assurance Report
Agenda Item: PUB24/05/3.3
Committee Date: 27 March 2024
Meeting Chair: Catherine Glickman – Non-Executive Director and Committee Chair
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
Access to the Stack
Consideration: 6-month update, reviewing progress within Clinical strategy – focus on Cleric portal as digital transmission, acceptance and incident rates, staffing against EEAST’s commitments, data provision.
Resolution/Outcome: Cleric is working as the digital portal: in February 3505 calls transferred: 72% acceptance by 20 minutes (percentage varies by ICB). 24 incidents in last 6-months – none caused harm. Passback now digitally enabled. EEAST’s staffing commitment (7-days, 12-hours per day) proving difficult to deliver on given EOC pressures – under discussion. Data and dashboards under development.
Assurance: Moderate
Medical Devices Report
Consideration: A comprehensive report covering compliance; tracking, replacement and maintenance; introduction of new equipment and group oversight.
Resolution/Outcome: The Committee were deeply reassured by the report. Specific points highlighted were: 95% compliance; replacement programme on track; RFID tracking of all devices with agreement to invest in eQuip, a specific database for tracking devices. Analysis of device breakdowns had reduced the ongoing failure rates. The Medical Devices Group was working effectively. ISO:13485 had been achieved in January 2024. Risks identified by the Committee were staff downloading non-approved devices which had been seen in other trusts (unlikely because of our firewalls) – this would be checked for security, and procurement of devices without Medical Devices approval – this needed to continue to be tightened across the Trust.
Assurance: Substantial
Integrated Performance Report
Consideration: The Committee reviewed the metrics, which included updated data for Learning from Deaths.
Resolution/Outcome: The Committee congratulated the progress on Bare Below Elbow at 95%; Learning from Deaths – 19 clinicians trained with aim of achieving target of 46 per month by April. One SI outstanding, expected to close end April; embedding PSIRF ongoing.
Assurance: Substantial
Clinical Audit Plans
Consideration: The Head of Compliance Natalie Mudge updated the Committee on progress on the 2023/24 plan - on track for completion.
Submission of 2024/25 plan: includes new category of falls in the elderly.
Resolution/Outcome: The Committee recognised and were pleased with the progress on the 2023/24 Clinical Audit Plan. The proposed 2024/25 Plan was approved with no changes.
Assurance: 2023/24 Plan: Moderate, expected to move to Substantial at year end.
Frequent Ambulance Service User
Consideration: Simon Chase updated on the report and recommendations which were on track.
Resolution/Outcome: A detailed update would be provided to the June meeting.
Assurance: N/A
Subcontractors: Private Ambulance Service
Consideration: A short update to confirm the appointment of a General Manager to oversee PAS and complaints and concerns remained similar.
Resolution/Outcome: The Committee received the update.
Assurance: Moderate
Subcontractors: Volunteer Services
Consideration: An update on plans to ensure quality recruitment of volunteers and ongoing training.
Resolution/Outcome: The Committee received the update, but raised whether we were using the available hours effectively to support response times.
Assurance: Moderate
Quality Account Local Priorities for 2024/25
Consideration: The 2024/25 Quality Account will focus on:
- Patient Safety – Learning from Deaths, embedding the PSIRF, After Action Reviews
- Clinical Effectiveness – reducing on-scene time for STEMI and stroke, safe discharge left on-scene, optimised pathway for falls
- Patient Experience: surveys, increasing diversity of engagement groups
Resolution/Outcome: The Committee supported the Quality Account Local Priorities: getting more feedback from patients and carers was seen as a priority, which Healthwatch may be able to support with; the Committee asked that how the Trust was applying learning across the organisation be a key area of work for 2024/25.
Assurance: Approval of the Quality Account Local Priorities.
Legal Services Update
Consideration: An update from Legal Services: there is still a backlog of cases, and cases have doubled in 2023/24; they are increasingly complex, often with legal representation by those involved.
Resolution/Outcome: The Committee debated the Preventing Future Deaths notices (7 in 2022 and 2023, 2 in 2024) – most relating to response delays and one relating to child asthma. The volume of cases may mean the use of external legal experts over the summer to meet coroner deadlines: the Committee asked to be updated if this was the case.
Assurance: Moderate
Regulatory Assurance Report
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
Board Assurance Framework
Consideration: The residual risks remain high.
Resolution/Outcome: The committee supported the conclusions of the paper, noting that following workshops, the risks were being updated. The Committee asked whether, given the medical devices report, the risk profile could be reduced, and clinical supervision was now in place, so risk register should be updated.
Assurance: Moderate
Group Assurance Report
Consideration: The Committee reviewed the report.
Resolution/Outcome: Groups had met since the last meeting and provided assurance of progress.
Assurance: Moderate
Quality Governance Annual Report 2023/24
Consideration: The annual report format and content was talked through.
Resolution/Outcome: The Committee supported the planned approach for 2023/24’s Report and agreed an additional meeting in June to sign off.
Assurance: -
Matters for escalation or referral
None
