CLINICAL GOVERNANCE ANNUAL REPORT

2009 - 2010
Contents Page

INTRODUCTION ...................................................................................................3
PERSON CENTRED .............................................................................................4
Patient Experience .......................................................................................6
Complaints and claims .................................................................................8
CLINICAL EFFECTIVENESS ................................................................................11
Staff Training ..............................................................................................12
Quality Improvement Projects & Audits Supported.....................................13
National Standards and Guidelines ............................................................16
Integrated Care Pathways (ICP).................................................................17
SAFETY ...........................................................................................................19
Patient Safety .............................................................................................19
Risk Management ......................................................................................21
APPENDIX 1 – CLINICAL GOVERNANCE ACTION PLAN.........................................22

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Introduction

The concept of Clinical Governance was introduced to NHS Scotland in the Scottish
Executive White Paper “Designed to Care” (SEHD, 1997) to ensure that quality of
care is given the same prominence as other key drivers such as finance and staffing.
It has been described as “corporate accountability for clinical performance” and is the
system for ensuring that healthcare is safe and effective and that patients and the
public are involved.

Within NHS Tayside a more streamlined collaborative framework has been

developed for Clinical Governance to prevent unnecessary duplication and support
the integration of clinical governance, risk management and patient safety, and
commits to collaborative working between departments. The framework for Safety
Governance and Risk will be aligned with the new Quality Strategy announced by the
Cabinet Secretary for Health and Wellbeing in February this year. This report is
constructed to reflect the three key drivers of the strategy:
• Person Centredness
• Effectiveness
• Safe

A review of the Clinical Governance arrangements across NHS Tayside commenced

in 2008. Recommendations from the Phase One of the review have been
implemented, resulting in the integration of the following departments into a wider
Safety, Governance and Risk (SGR) team:
• Complaints and Claims
• Dundee CHP Clinical Governance team
• Public Involvement team
• Risk Management (including Patient Safety)
• Tayside Audit Resource (TARPC) including the Mental Health Clinical Governance
Team

This team is line managed by the Acting Head of Safety, Governance and Risk.
Team meetings for the Integrated Safety, Governance and Risk team are also
attended by the Secondary Care Clinical Governance team.

A presentation of the review to date was given at the Executive Management Team
meeting in March 2010, outlining progress so far, line management proposals for
service delivery, including the development of Quality Improvement Delivery Groups
and options for the future infrastructure. Agreement was made that there should be a
single Safety, Governance and Risk team across NHS Tayside. The next stage of
the review will involve working in partnership with staff, Staff Side and Human
Resources on moving this forward.

This Clinical Governance Annual report aims to provide members of the Improvement
and Quality Committee with an overview of the work undertaken across Safety,
Governance and Risk and highlights any challenges, throughout the period of 1st
April 2009 and 31st March 2010.

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Person Centredness

The Public Involvement Team with SGR colleagues have provided advice and guidance on
developing engagement plans and identifying methods for involving patients, carers and the
public across NHS Tayside in numerous and wide ranging areas from service change and
improvement activities to patient surveys and capital projects. These have included support
and facilitation in the development of the new wheelchair user group, public participation in
developing plans for nuclear medicine facilities, public involvement in raising awareness of
hand hygiene in Healthcare Associated Infection, the advice given also takes cognisance of
the Informing Engaging Consulting Guidance on involving people in service change.

The Public Involvement Team also facilitates the involvement of the Public Partnership
Groups in committees, groups, events, discussion forums and information sharing sessions
including membership of CHP Committees, food tasting audits, policy development and
external engagement activities with Universities and the Scottish Government Health
Department.

The Patient Focus Public Involvement Operational Group led by the Public Involvement
Manager comprises of representation from across the organisation and has a remit to ensure
that systems and processes are in place to enable patients, carers and members of the public
to be actively involved in the planning and development of NHS Tayside services. This also
provides a platform to share good practice and outcomes for involving people. The group
reports into the Tayside Improvement Panel.

The team also work closely with the Scottish Health Council in the development, assessment
and evaluation of Patient Focus Public Involvement Activities across the Board.

Electronic Stakeholder Portal

An electronic stakeholder consultation portal is being developed in partnership with NHS
Scotland Health on the Web team. The online discussion forum has been tested and used by
the Public Partnership Group and Dundee Youth Council. Further elements including online
surveys and e panels are being developed.

Public Partnership Groups

Public Partners have been involved in around 150 engagement activities in the year
to help NHS Tayside gather and take cognisance of public opinion in service
improvements and change. These activities continue to increase year on year. The
success of the Public Partnership Groups has led to a review of their role in an
attempt to meet the demand of their services. The Public Involvement Team has
engaged with group chairs and members over the year to explore ways of working
together in the future. This has resulted in the agreement of a network of public
partners who will respond to NHS Tayside requests for their involvement and also the
development of a team of community researchers who will identify and raise issues
and challenges with the NHS. Additional recruitment has already started and will
continue in earnest in the year ahead.

Volunteer Services
During 2009/10, a new ‘volunteer welcome desk’ has been established at Ninewells Hospital,
with the volunteers themselves organising the rota and cover. Figures collated demonstrate
an increase in activity throughout the year.

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Volunteer recruitment in other areas of the hospital has also increased so that Ninewells now
has approximately 140 volunteers with additional volunteers in other volunteer services e.g.
Radio Lollipop, Spiritual Care etc. NHST is applying for the Investors in Volunteering award
this year and preparations are well underway for this.

Interpretation and Translation

Interpretation and translation services continue to develop across NHST. A new Policy has
been ratified as has a new Service Level Agreement with Dundee City Council for the
provision of face to face interpreting and translation services.

Children and Young Peoples Learning Event

This event was organised and hosted by P&K CHP with representation from statutory
and voluntary services as well as young people from a variety of organisations. The
aim of this event was to bring together agencies and services working with children
and young people, as well as young people themselves, to discuss current and future
services available and methods for future engagement.

Key Challenges for the next 12 months

• Supporting community members in the development of the public partner community
researcher role which will lead to greater challenge for NHS Tayside in its delivery of
services.
• Recruitment of people to increase the capacity of the public partner network.
• Implementing and testing the developing Electronic Stakeholder Portal for online
consultation and engagement.
• Working with the new Participation Standards and framework which will be how Patient
Focus Public Involvement activities will be measured and reported on from 2010.

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Patient Experience

Patient Feedback
Better Together is an improvement programme to gather feedback from patients and staff in
order to improve NHS services in Scotland. It is part of a wider programme of ongoing
feedback and improvements in the NHS in Scotland. It is designed to help make the NHS in
Scotland a truly “mutual” NHS, “one where we all take more control of our health and become
more active in deciding how our NHS is run”. A Patient Experience and Better Together
Project Board was established in NHST, chaired by the Board Nurse Director. A contractor for
the survey work was agreed and The Better Together national patient survey was sent out at
the beginning of 2010, with preliminary results anticipated in July 2010. Plans are in place to
address how to take forward results from this survey in collaboration with service improvement
and other colleagues which they are testing at present and a robust communication plan to
inform patients and the public is underway.

Patient Stories Group

A Patient Stories Group has been established specifically to enable the sharing of good
practice and ‘join the dots’ in relation to ‘story’ activities across Tayside. There is wide
representation and examples of good practice shared, e.g. work with digital stories, learning
from complaints, ‘You Said We Did’ work, use of the electronic portal, patient related
outcomes, focus groups and ‘emotional touch points’. The group reports through to the Patient
Experience and Better Together Project Board.

‘You Said We Did’

Within NHS Tayside we are gathering patient feedback locally on a continuous basis to bring
about improvements the “How Are We Doing?” questionnaire is a brief, four-question
questionnaire, which has been adapted for use across many areas of NHS Tayside, including
the acute setting, CHPs and mental health. Comments from patients are displayed via a
feedback board, based on a “you said, we did” format. Improvements from this methodology
include changes within radiology improving aspects of privacy and dignity for patients by not
asking all patient to wear gowns before their x-rays; other improvements are to fabric and
layout of waiting areas, reduced noise at night and appointment times for patients coming to
clinic, to patient information, changes to domestic services, introducing additional activities on
rehabilitation wards and changes to the environment (e.g. additional payphones being made
available). This work featured as one of only two case studies in the Better Together launch.

Ask me 3
‘Ask me 3’ is an initiative aimed at all users of our health service but in particular
those with poor literacy. It is estimated that 23% of the adult population in Scotland
have a poor level of literacy and a further 30% of adults in Scotland feel their level of
literacy is inadequate. There is a large amount of evidence that shows poor literacy
correlates to poorer health engagement and poorer health outcomes. Ask me 3
encourages patients to consider questions relating to their health and treatment in
advance of their appointment with their clinician. Ask me 3 is a very simple leaflet
that promotes communication between clinician and patients. It encourages patients
to gain understanding in three key areas of “what is wrong with me?”, “what do I need
to do?” and “why is this important?”. Small tests of change were conducted in the
orthopaedic and ENT outpatient departments and feedback from patients was very
positive. Common feedback was “not forgetting to ask about important questions”,
“putting mind at rest” and “gave me a good idea of what to ask”.

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Two consultants within orthopaedics have introduced Ask me 3 to their clinics and it
is planned to spread this to other orthopaedic surgeons. All ENT patients will now
receive the Ask me 3 leaflet with their first appointment. There are also plans to test
its use in other areas of the Organisation, including Ophthalmology, Plastic surgery,
Neurology and General Surgery.

Patient Centredness Questionnaire

Work is underway to validate a CARE tool which has an emphasis on the patients
experience based upon the care they have received at a local level. This will
complement the Better Together initiative. The tool is a questionnaire which is
themed into empathy, involvement in decision making, care and food and nutrition.
These themes may change, as might the actual questions during the validation
process. It is planned to have this questionnaire as part of a library of Clinical Quality
Indicators for clinical areas which include pressure area care, food and nutrition and
falls prevention. It is planned to have the validation process confirmed later this year
and to start the spread of the questionnaire to clinical areas soon after.

“Talking Feet”
A tool was developed to allow children to provide feedback on the experience they had
attending the Podiatry service. This tool consisted of large, bright posters of feet that the
children could put stickers on reflecting their experience. This novel method of engagement
allowed feedback to be provided from service users who may not previously been given the
opportunity to do so.

Macmillan Day Care Focus Groups

Engaging service users in focus group sessions to evaluate a new assessment process, staff
competencies, support and overall user satisfaction.

Aphasia Groups
Engaging service users in focus group sessions to test naming strategies for word association
and coping strategies when using different forms of communication.

Centre for Brain Injury Rehabilitation (CBIR)

Currently testing a new patient-focused outcome measure in CBIR, which incorporates
mutually agreed goals set on admission by patient and clinician. Performance is then
measured throughout the patient’s admission and then individually and cumulatively analysed
on discharge.

Key Challenges for the next 12 months

• Implementing improvement plans from the Better Together Survey

• Developing an action plan to take forward the implementation of the Patient Rights Bill
• Sustaining the obtaining of local feedback for improvement which compliments the
macro level feedback from the Better Together survey

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Complaints and claims

Rapid Improvement Implementation

The actions from the Rapid Improvement Event held in December 2008 have been
spread throughout Women and Reproductive Health and good progress is being
made to continue the spread throughout the Medical Directorate. Progress has also
been made in the three Community Health Partnerships and the Surgical Directorate.
The spread includes a complaints resource folder supported by an initial training
session and provides information and support for frontline staff to deal with any
issues raised in the local area. It is planned that spread will be complete by the end
of 2010.

Reduction in top 3 themes from complaints (Communication, Clinical Treatment &

Staff Attitude)
The expectation with the introduction of the Rapid Improvement Event work in areas
is that the three themes would be reduced by local monitoring using the resource
folders and this would then be fed back to staff. Themes from complaints can be
analysed and compared with themes from the corresponding previous 12-months.
This analysis has enabled improvement plans to be put in place at local level. It is
predicted that the themes will change as the culture within the organisation begins to
embed, encouraging and obtaining real time feedback from patients. Early resolution
of minor complaints and obtaining real time feedback as a matter of routine will also
result in a reduction in the overall number of complaint

Compliance with and achievement of 20-day target

Following a period of major review and evaluation of systems within the Complaints
and Advice Team there has been significant improvement in response times over the
last year. At the time of reporting, the average for 2009/10 is 80% which meets the
target of 80% set by NHS Tayside. (2008/09 - 57%). It is expected that this response
rate will be maintained.

Sharing learning from complaints

There are area-wide procedures in place for collecting and disseminating the
information, themes and good practice gained from patients’ views, experiences and
complaints and are ensuring that they are used to improve service quality. The
Complaints and Advice Team disseminate this information by attending Clinical
Governance Forums, the Adverse Incident Management Group and the Health and
Safety Risk Management Group. Complainants are also actively encouraged to
provide feedback regarding the quality of formal responses.

Feedback from the snapshot questionnaires developed during the Rapid

Improvement Event has provided an opportunity to improve the quality of formal
responses sent to complainants. Some of the feedback obtained identified that a face
to face approach may have resolved the complainants concerns earlier and would
provide an opportunity for staff to apologise in person rather than through a formal
response letter. This feedback has been used as a point of learning within the
Complaints and Advice Team and within the Directorates and CHPs and a higher
number of complaints are being resolved using this face to face approach. Further
snapshots will be undertaken quarterly to maintain the cycle of improvement within
the organisation.

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The implementation of a Service Improvement Loop is currently being explored. This
will provide a robust system to ensure that learning from issues raised in complaints
is monitored closely and any service improvements are shared within the
organisation and reported to the Tayside Improvement Panel. This will be a
collaborative effort between the Safety Governance & Risk Team, the Clinical
Directorates and Community Health Partnerships.

Scottish Public Services Ombudsman

The Scottish Public Services Ombudsman (SPSO) produces monthly reports on
complaints investigated in NHS Scotland by the Ombudsman’s team, which are a
valuable source of information. These are widely distributed throughout the
organisation including to the Clinical Governance Forums, General Managers, the
Clinical Governance Chairs Group (Secondary Care), Tayside Improvement Network
and the Adverse Incident Management Group. These are considered as agenda
items at Clinical Governance Forums and actions and improvements are driven via
the Clinical Governance reporting template.

In NHS Tayside, a process of demonstrating evidence of learning from all

Ombudsman recommendations has undergone several tests of change. This is
currently undergoing a further test of change and the outcome will be reported in
future papers. The challenges involved in this process have included the complexity
of the recommendations and the range of clinical areas involved. The current process
undergoing a test of change focuses on individual themes and will involve key
stakeholders benchmarking current systems and processes against Ombudsman
recommendations.

To date, in 2009/10, nine reports relating to NHS Tayside have been published, eight
of which were upheld or partly upheld. In the previous year (2008/09) there were 12
reports published, nine of which were upheld or partly upheld. There is no correlation
in terms of timescales and there is significant variance between the date of the
complaint and the date of Ombudsman report publication. For example, one of the
complaints investigated and reported by the Ombudsman in July 2009 related to a
complaint initially raised in November 2006. This may be caused by varying degrees
of complexity of the complaint and the processes within the Ombudsman’s
department. Furthermore, it should be noted that complainants have up to 12 months
from the initial complaint to proceed to the Ombudsman. Given that there is a
significant delay between the complaint being made and final reporting by the
Ombudsman, many of the improvements recommended are either already in place or
underway.

Fatal Accident Inquiry

Following a system review, an improved process of agreeing the actions and
completing these within three months of receiving the Sheriff’s Determination and
Recommendations in a Fatal Accident Inquiry is now in place. This process ensures
that key leads are collectively involved in the actions being agreed and that deadlines
are met. Following a recent Sheriff’s Determination in August 2009, an agreed action
plan was in place within three months and is continually updated.

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Key Challenges for the next 12 months

• Implementation of Service Improvement Loop.

• Continuing spread of the RIE action plan.
• Maintaining and improving upon the improved response rate.
• Reviewing and reporting strategy for complaints and legal claims data.

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Clinical Effectiveness

The integration of departments within Safety, Governance and Risk has continued during
2009-10, resulting in shared skills and reduced duplication. There has been an increase in
working across teams to deliver on a shared aim, and staff have been given opportunities to
move within the team to share learning and build capability for future work. Key contacts have
been identified from within Safety, Governance and Risk who will work closely with clinical
services to identify what support they require and who is best skilled to provide this support.
This will afford opportunity to test hub working across the Organisation. The Acting Head of
Safety, Governance and Risk has worked closely with the Associate Director of Change and
Innovation to agree key programmes of work for 2010-11.
Opportunities for increased joint working with other departments within NHS Tayside have
also been pursued, and examples include:

• Working in conjunction with multi-disciplinary teams and external service providers to

implement LEAN methodology when delivering on:

Virtual Wards

Continuing Care Beds

Sexual Health
• Working in conjunction with medical and clinical staff to deliver patient-centred outcomes
for measuring patient goals in:

Centre for Brain Injury Rehabilitation

Day Hospital

Macmillan Day Care
• Working in conjunction with mental health services, general practice, health strategy and
service improvement to develop and implement an electronic referral pathway that
includes a triage process.
• Working with colleagues in eHealth to develop a clinical dashboard to provide graphical
displays representing core quality measure tools for both operational and clinical use.
The key is to have data inputted once and used by many, measuring what matters as
opposed to what is available. The dashboard will enable staff to access data which often
sits in silos and make linkages and correlations, giving greater understanding of cause
and effect of the complex clinical environment. This together with locally determined
parameters can assist in improving quality, performance and patient experiences.
Dashboards will:

provide timely feedback against locally predetermined parameters to assist successful
intervention and improvement.

offer an active monitoring tool for clinical engagement, operational effectiveness,
clinical outcomes and patient experience.

give opportunities to detect emerging patient safety issues and permit timely mitigating
actions to be taken.

Reporting has also been streamlined, with all Clinical Governance Fora now using the same
format of exception reporting. A Delivery Unit Clinical Governance Report is reported to the
Tayside Improvement Panel every six months and a Delivery Unit Clinical Governance Update
is reported to the Improvement and Quality Committee at each meeting. These reporting

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mechanisms have been commended by the review team from NHS QIS during the recent
peer review visit in February 2010.

A report was submitted to the Improvement and Quality Committee at its meeting in November
2009 highlighting that future reports will provide assurance to the committee through
evidencing that the three key drivers of the Quality Strategy are being undertaken.

The sections below will provide specific details on the key clinical effectiveness areas of
clinical audit, national standards and guidelines, and integrated care pathways.

Staff Training
NHS Tayside offers a comprehensive annual training programme on quality improvement
skills to all staff. The training programme is run in conjunction with NHS Fife and is accredited
by Dundee College, with successful participants receiving a Certificate in Quality Improvement
Models. In addition to providing the skills to undertake quality improvement work, participation
in this programme will also assist in developing evidence for the Knowledge and Skills
Framework (Core Dimension 4: Service Improvement, and Core Dimension 5: Quality).
Since the programme started in 2008, 37 participants have successfully completed the
Programme. As part of the Programme, participants showcase their skills at a Sharing Good
Practice day attended by staff from NHS Tayside and NHS Fife. A wide range of quality
improvement work is shared, using a wide variety of improvement tools with outcomes linking
into service priorities. Following this, participants have also submitted posters of their work to
national conferences, and one participant has written an article that has been submitted to
their professional body publication to further share the learning. Previous participants have
continued to demonstrate the skills they have learned by continuing with quality improvement
work after completion of the programme with support from the Safety Governance and Risk
team.
Examples of the improvement projects undertaken as part of the Programme during 2009
include using the process mapping and the Model for Improvement to reduce the average
length of stay in one community hospital ward, by 60% for stepdown care and 75% for GP
admissions; using the Model for Improvement and staff questionnaires to standardise an
Occupational Therapy assessment process, reducing the average time taken to administer the
assessment from 6 hours to 75 minutes, whilst increasing the validity of the assessment
outcomes by ensuring it is administered in the standardised way; and doubling the number of
patients seen by the Mental Health Physiotherapy service by changing work patterns to
include evening sessions, and measuring patient satisfaction with the new working hours.
Twenty-three people have signed up to participate in the Programme during 2010.

In addition, a similar programme is in place for staff working within General Practices across
NHS Tayside. In response to requests from General Practice, this programme takes two
years to complete instead of one, but participants work towards the same outcome of a
Certificate in Quality Improvement Models. There are currently 12 participants on this
programme.

Training for medical staff has been integrated to provide sessions covering Patient Safety,
Risk Management, Clinical Governance and Complaints and Claims, which has provided an
opportunity for staff to explore the relationship between the different components. This
training has more recently been reviewed to reflect the national Quality Strategy. Feedback is
gained from participants to allow the training to continue developing to meet their needs.

In addition, support has been provided with a wide range of other training, e.g. risk
management, incident review, complaints awareness and patient safety training.

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Along with our colleagues within the Improvement Team, staff within Safety, Governance and
Risk have been trained to become Improvement Advisors through the Institute of Healthcare
Improvement. These members of staff will have a role in building capability through
developing skills across Safety, Governance and Risk.

Staff working across Safety, Governance and Risk have also accessed a wide range of
learning activities, including LEAN practitioner training, leadership training, coaching skills
training, seven habits of highly effective people training, shadowing opportunities, secondment
opportunities and opportunities to act as peer reviewers on behalf of NHS Quality
Improvement Scotland on the Clinical Governance and Risk Management standards. This
has given us an opportunity to share learning of what is happening in other parts of Scotland.
Many staff from across Safety Governance and Risk has completed modules in Clinical
Governance, Risk Management and Clinical Effectiveness provided by Glasgow Caledonian
University as part of the agreement with NHS Quality Improvement Scotland.

External Projects
A process was developed during 2008-09 to ensure that applications from external
organisations, and individuals, who approach the organisation seeking approval for
involvement in quality improvement work are dealt with consistently and ensure a record of
the work undertaken, including outcomes, is retained within the organisation. The process
was implemented across NHS Tayside. Ongoing monitoring of the process has identified
some flaws, and work is underway to test solutions and strengthen the procedure. To date,
31 projects have been approved.

Internal Audit Report on Clinical Audit

During 2008, an evaluation was carried out on the organisational processes for clinical audit
by the Internal Audit Department. The report recognised that, where staff sought advice and
support from clinical governance teams, the support given to carry out an audit was sound
and the improvement sustained. However, it also recognised a number of areas for further
development and improvement, including:
• The development of a clinical audit register
• Development of a system for costing clinical audits
• Continuing the work with clinical areas to strengthen clinical effectiveness and
improvement work.
An action plan was developed and implemented to address the issues from the evaluation. A
paper was submitted to the Audit Committee in September 2009 reporting on the
implementation of the action plan, which has been completed. The effectiveness of the action
plan will continue to be monitored and any necessary actions to improve systems and
processes taken.

Quality Improvement Projects & Audits Supported

Below are examples of some of the projects/audits that staff have supported and facilitated
throughout 2009/2010:

Informed Consent Audit

In April 2008 a complaint relating to consent was upheld by the Ombudsman and, as a result
an audit of the consent form was conducted across clinical areas within NHS Tayside. The
audit identified that overall completion of the consent form by clinicians was fair although
identified areas for improvement

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As a result of the audit, a revised informed consent policy was ratified by the Medical Director
in Autumn 2009 and a new consent form has been implemented across the organisation using
PDSA methodology. Some areas continue to test local adaptations of the form.

Palliative Care
The Dundee CHP Clinical Governance Team has been working in collaboration with
colleagues from Palliative Care to measure patients’ satisfaction with the assessment process
at the Macmillan Day Care Centre. Satisfaction with the service is analysed on a bi-annual
basis with measures in place to gauge anxiety levels prior to and following initial assessment,
involvement in planning of care and staff competencies.

Hand Hygiene self assessment questionnaire

As part of the ongoing work in relation to improving compliance with hand hygiene in P&K, the
Quality Improvement Team was involved in testing the Hand Hygiene self assessment
questionnaire. This questionnaire assists services to identify staff knowledge in relation to
hand hygiene guidance, and where to target education needs. This had been previously used
within General Practice, and was adapted for testing within the Podiatry department.
Following this successful test, this questionnaire has now been used by all AHP services
within P&K, the Medicine for the Elderly Day Unit, and is about to be used in Pharmacy.
Angus CHP has now also taken this questionnaire, and is using it in Community Services.

Infection Control Table Top Exercise

In Angus CHP an infection control table top exercise was undertaken to enhance and inform
operational Infection Prevention and Control Policy and local procedures that raise
awareness, set out roles and responsibilities of all staff to improve infection prevention
measures across Angus CHP.
A programme of hand hygiene master-classes have been organised to provide all staff with a
robust understanding of hand hygiene. This will enable improvement in completion and
compliance in the opportunity audit tool, in addition to providing an update in technique.

Carers Health Checks

Within Perth and Kinross a multi-agency P&K Carers Strategy Implementation Board
has the responsibility for ensuring the roll-out of the carers’ strategy and monitoring
the progress on an on-going basis. The strategy contained two actions specifically
relating to the health of carers and one of these areas was taking forward a carers
health check pilot. Staff supported the following:

• Developing guidelines for the nurses in relation to the monitoring and evaluation
and training was provided.
• Developing databases for completion by pilot areas nurses which were then sent
to the Quality Improvement Team on a monthly basis for collation.
• Developing and distributing patient, staff and practice questionnaires.
• Completed evaluation and shared report.
• Recommendations for the future

PRI Stroke RIE and ongoing Improvement work

Following the Stroke Rapid Improvement Event in February 2009, Clinical Governance staff
have been involved in supporting ongoing improvement work relating to ensuring reliability of
pathways and adherence to the NHS Quality Improvement Scotland Stroke Standards.

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Pathways are now in place for A&E, Ward 4 and Radiology, and work continues to
consistently achieve the QIS Stroke Standards. Other evaluation of the service planned is for
patient and carer questionnaires as well as investigating the use of patient stories for service
users.

Healthcare Records Audits

In December 2008, a records audit was undertaken across the Delivery Unit. This highlighted
a number of areas requiring further action and improvement. The audit results were reported
to Tayside Improvement Panel in April 2009, along with examples of agreed actions from local
areas. Following the audit, clinical areas were provided with a tool to monitor continuous
improvement over time against the standards.

A second audit cycle undertaken in December 2009 demonstrated improvement in record

keeping standards. Local reports from this audit have now been disseminated to local teams,
with these teams producing local improvement plans. Improvements have been achieved
through a number of initiatives including revised nursing records, new informed consent form,
staff training and development of standard operating procedures.

All clinical areas are now moving towards reviewing five sets of notes a month, rather than
annual audit programmes, to ensure that feedback and action is more timely.

Key Challenges for the next 12 months

• Ensuring that the “loop” is closed, and that improvements to practice are measured.
• To establish a methodology for auditing the quality of records within services which use
primarily or solely electronic records (Community Dentistry, Pharmacy).

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National Standards and Guidelines

Staff have participated in the preparation, evidence collation and review visit for a number of
NHS Quality Improvement Scotland assessments, including the following:
• Anaesthesia
• Clinical Governance and Risk Management
• Endoscopy
• Learning Disabilities
• Hospital Acquired Infection (HAI), including Healthcare Environment Inspectorate (HEI)
visit to Ninewells Hospital
The review of action plans from these visits are monitored though the Tayside Improvement
Panel.

Preparation has also been underway for the following visits in 2010/11:
• Healthcare Environment Inspectorate (HEI) visit to Perth Royal Infirmary

Work is also in progress in relation to the Sexual Health Standards, which were published in
March 2008. This topic has been identified within the NHS QIS programme of work for
2010/11 but no specific dates provided. In the meantime, work is underway to evaluate the
service and collate evidence to support the self-assessment issued to NHS Boards in July
2009.

Good progress is also being made for foundation accreditation against the NHS QIS
Standards for Integrated Care Pathways for Mental Health.

Clinical Governance Team members act as reviewers for the Quality & Outcomes Framework
(QOF), and for QOF Plus. They have been involved in several assessments within General
Practices over the past year.

Following on from our test with SIGN Guideline 99 – Management of Cervical Cancer, we
continue to evaluate and improve the system and processes for implementing SIGN and NICE
guidance within NHS Tayside. Work has been undertaken to streamline the mechanism for
distribution of SIGN Guidelines, with a view to having one point of contact within NHS
Tayside, promoting electronic distribution rather than hard copy and avoiding unnecessary
duplication. In addition, further clarity is required regarding individual responsibility for further
dissemination and implementation of guidelines. Feedback on the current situation and
proposals for the future were sought via a telephone survey and questionnaire and the results
shared with the Tayside Improvement Network (TIN). Recommendations for further work
were agreed, with a follow-up report to TIN due in September 2010.

Key Challenges for the next 12 months

• Meet the HEAT target relating to Clinical Governance and Risk Management Standards
• Deliver actions from the NHS QIS Review Visits e.g. Anaesthesia, Clinical Governance
and Risk Management, Endoscopy, Healthcare Environment Inspectorate
• Implement system wide actions from the Learning Disability Review

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Mental Health Integrated Care Pathways (ICP)

The Admission and Discharge ICP has evolved into the Generic ICP, which consists of three
components;
• Assessment Pack
• Community Pack
• In-patient Pack – with an abridged version to accommodate the situation when a patient
is admitted with a live Community ICP.

The Admission and Discharge ICP has been implemented across inpatient mental health
services in Tayside.
• Variance analysis continues for the In-patient setting, with a plan to address the
variances systematically, thereby reducing them to manageable levels, before shifting
the focus once full compliance has been achieved.
• The ICP will be reviewed in November, six months after this version has been
introduced, to take into account any issues identified in its use. This will give the
opportunity to resolve issues, and to fine tune the process.
• Link Co-ordinators have been identified to introduce sustainability into the process thus
removing the dependence on the ICP Co-ordinator
• Further training is planned with link workers in each area, with additions to this network
to facilitate feedback to the support group, and allow best practice to be shared
affectively. The variance analysis process will in time, be streamlined by moving it to
team level, thus empowering staff to make decisions more pertinent tot heir particular
area
• Utilising the variance data to improve patient care. Meaningful use of data will underpin
the cycle of continuous improvement, and raise the awareness of issues that need to be
addressed.

NHS QIS Mental Health ICPs

The NHS QIS Mental Health ICPs comprise of a generic pathway focussing on:
• Referral processes
• Assessment processes
• Care processes
• Review processes
• Discharge processes
There are also five condition specific pathways (bipolar affective disorder, borderline
personality disorder, dementia, depression and schizophrenia). These pathways will dovetail
with the generic pathway at the diagnosis stage of the patient journey. The Condition Specific
ICPs are being agreed, with a presentation set for May 2010 allowing some stakeholders who
were not involved in the development stage of the process to consider the ICPS and how they
can be used.
Foundation Accreditation has been achieved, however, the criteria for the next level of
accreditation have yet to be announced. MiDIS has been successfully introduced to some
areas, and the roll out to other areas is underway. Documentation to ensure the universal

17
element of the ICP has been forwarded to the MiDIS Team, and they are building electronic
versions to accommodate the ICP process.

A Strategic drive is currently underway to target the areas of referral and assessment
processes, which will in turn augment the work already begun by the ICP process.

The ICP Co-ordinator secondment is currently under consideration due to the NHS QIS
timescales being extended. Support to the co-ordinator is provided by the Safety Governance
and Risk team.

Perinatal Mental Health ICP

The exit strategy for this project was completed in August 2009 with the project manager
returning to their substantive post however time has been allocated within that substantive
post to allow some continuance of activity with their clinical role. The ICP is now hosted within
Women and Child Health directorate and the Tayside Perinatal Mental Health Steering Group
continues to meet on a quarterly basis. The variance analysis of the ICP is supported by the
Safety Governance and Risk team across the delivery unit as stated in the exit strategy for the
project post.

Key Challenges for the next 12 months

• Next level Accreditation for ICPs

• Embed the Generic ICP process for Mental Health across NHS Tayside, with built in
sustainability, guiding clinicians in the use of variance analysis to influence improvement
and sharing good practice.
• Agree variances for Community and Psychiatry of Old Age,
• Share findings with Learning Disability and Child and Adolescent Mental Health
Services.
• Introduce the Condition Specific ICPs into NHS Tayside, after appropriate testing to
ensure viability of the same.
• Building of the ICP in MiDIS to ensure sharing of information with other relevant parties
and reduction of completion of documentation.

18
Safety

Patient Safety
Our patient safety activity is divided into five workstreams: leadership, general ward care,
perioperative care, critical care and medicines management. Each of the workstreams is
assigned an executive sponsor from the leadership team with the influence and authority to
allocate the time and resources necessary to achieve the front line team’s aim and to remove
barriers to progress as the team encounter them. Each workstream has dedicated support from
the Safety Governance and Risk team across the delivery unit.

Clinical Governance staff have collaborated with the Patient Safety Development Manager to
support the spread of the Scottish Patient Safety Programme across NHS Tayside. This
includes assisting with spread across the organisation, including community hospitals. Staff
involvement includes representation at national learning sets, delivering training, support to
carry out tests of change and support with measuring improvements. In Perth & Kinross CHP, a
Hospital Acquired Infection Forum meets on a two monthly basis with representatives from all
services to discuss key areas relating to maintaining and improving components of the HAI
balanced scorecard.

Our four strategic aims set out in NHS Tayside’s Strategic Plan 2010-2015 represent a coherent
set of goals mapped clearly to the Triple Aim Model. Our third aim focuses on the elements of
quality as set out in the National Quality Strategy which includes continuing to improve the
safety of patients, no matter where they are receiving care. We are doing this by spreading the
Scottish Patient Safety Programme and building on programmes to improve safety in mental
health, community hospitals, maternity and primary care services. . The collaboratives provide a
powerful source of learning, experience, and measurement that is further developing our skills
and knowledge in coaching others in improvement.

NHS Tayside is working alongside three other NHS Organisations in the UK on the ‘Improving
Safety in Mental Health’ Programme, which has been funded by The Health Foundation. This
is a fifteen month collaboration aiming to improve the reliability of care and reducing harm
within mental health services. This Programme is due to finish in June 2010, however the
Leads within NHS Tayside are developing plans to continue this work after the end of the
Collaboration, by aligning the measures and work steams with those within the Scottish
Patient Safety Programme.

In addition, The Health Foundation has also funded the Safety and Improvement in Primary
Care Programme, which NHS Tayside is participating in alongside NHS Forth Valley, NHS
Fife and NHS Lothian. This work is also supported by NHS Quality Improvement Scotland
and NHS Education Scotland. The Programme will be formally launched in May 2010, when
five local General Practices will be recruited. This Programme will test the use of patient
safety tools that are now used widely in an acute care environment within a primary care
setting, e.g. care bundles and trigger tools. In the second year of the Programme, it is
anticipated that a further 20 local practices will be recruited. The Health Foundation funding
will support Programme development costs and some funding to support backfill for
participating GP Practices. Support, facilitation and training will be provided for Practices
within existing Safety, Governance and Risk resources.

Key Challenges for the next 12 months

• Continuing to support learning regarding the Scottish Patient Safety Programme
methodologies as it spreads into further areas of the organisation

19
• Aligning and sharing learning from the Improving Safety in Mental Health and Safety and
Improvement in Primary Care Programmes with the Scottish Patient Safety Programme
• Testing and implementation of the Global Trigger Tool within Community Hospitals
(Perth & Kinross)
• Spread medicines reconciliation across the organisation
• Increased attendance at Global Trigger Tool reviews for specific areas
• Continue to align with NHS Tayside’s strategic objectives and help build internal capacity
and capability for improvement
• Implementation of the Safety Improvement in Primary Care

20
Risk Management

As the integration of teams into Safety, Governance and Risk progresses, the clinical
governance processes continue to develop to complement risk management. Clinical
Governance representatives are members of the Adverse Incident Management Group,
supporting clinical areas to learn lessons from incidents and spread the learning across
clinical groups and services. Risk management representatives are also invited to Chairs of
Clinical Governance meetings to ensure pertinent issues are raised and discussed.

Clinical Governance reports from services include progress with incident reviews and any
subsequent learning points. Within P&K CHP, there is an integrated Quality Improvement &
Risk Management Forum which discusses Risk Management and Health & Safety Issues
alongside clinical governance. This includes discussion of:
• All active SMART risks
• A summary of recent AIM incidents and any subsequent learning points
• Staff Health & Safety training
• Activity within service Health & Safety workbooks.

Capacity has been built across Safety, Governance and Risk for facilitation of Incident
Reviews at the request of services, and ensuring that following all sessions, an action plan
with outcomes and timescales is created, monitored and evaluated throughout. Staff continue
to undertake training for facilitating Incident Reviews via the E-learning module and provide
mentorship where required for others who are participating in this training. This builds on
previous opportunities to expand knowledge and skills around risk registers and Failure
Modes Effects Analysis (FMEA).

As capacity and skills grow, Safety Governance and Risk are able to demonstrate a reduction
in duplication at attendance at meetings. For example, one member of staff has been able to
support a service through their Steering Group to develop both their clinical governance and
risk management processes. Previously, this would have required one member of staff from
clinical governance and one from risk management.

Awareness of risk management processes have been built into quality improvement training
sessions. For example, within the Quality Improvement Models Programme, participants are
prompted to consider trends within their incident data when considering what improvement
project they will undertake. An awareness session on risk management and patient safety
has been developed as part of the Programme for staff from general practices, and they will
be encouraged to undertake an improvement project in relation to this.

Currently, consideration is being given to change from the Adverse Incident Management
(AIM) Business system to DATIX. Should this move go ahead, it is anticipated that staff from
across Safety, Governance and Risk would provide support to services with the change in
system.

Key Challenges for the next 12 months

• Further progressing integration through hub working and skills sharing

• Supporting the potential move to DATIX Business System

21
Appendix 1 – Clinical Governance Action Plan
Challenge
Implement actions arising from
internal audit report across NHS
Tayside
Ensure improvements are made in
response to audit/quality
improvement data
Ensure the “loop” is closed and
improvements made to practice
Sharing the improvements made
as a result of these projects
Action to be taken Evidence Responsibility Status
Separate action plan Current action plan Acting Head of

monitored through internal Safety Governance
audit process & Risk
Measures are attached to Clinical Audit database once implemented Clinical 
outcomes across the organisation will facilitate the Governance Teams
monitoring of audit activity
Individual project measures and outcomes
Clinical Audit Database is currently being used
within the CHP Clinical Governance Teams. To
seek support from Medical Director and
Associate Medical Directors for implementation
of database within secondary care and possible
link with Medical Revalidation.
Reporting back after Individual clinical governance reports via Clinical 
improvements are made clinical governance for a Governance Teams
Clinical Audit database once implemented
across the organisation will facilitate the
monitoring of audit activity
Clinical Audit Database is currently being used
within the CHP Clinical Governance Teams. To
seek support from Medical Director and
Associate Medical Directors for implementation
of database within secondary care and possible
link with Medical Revalidation.
Publication of projects in Copies of local newsletters e.g. Spectra Clinical

local and national media Copies of posters displayed at national Governance Teams
events
Add information to the A template to be devised to summarise Safety, Governance ☺
Safe & Effective pages of projects for publication on Staffnet & Risk Team
Staffnet
22
Challenge Action to be taken Evidence Responsibility Status
Projects presented at the Minutes and reports from the Tayside Acting Head of

Tayside Improvement Improvement panel Safety Governance
Panel & Risk

Sharing good practice
days
Ensure staff are choosing Create toolkit and publish
appropriate quality improvement on staffnet
tool from the toolkit
The programme from the sharing good Safety, Governance

practice days and abstract booklet e.g. & Risk Team
Certificate in Quality Improvement Models
to be held Dec 09.
Summaries of quality improvement tools to Safety, Governance

be developed and posted on Staffnet by & Risk Team
end of year

Ongoing provision of the Number of staff who attended the Safety, Governance

certificate in quality programme who obtained their certificate in & Risk Team
improvement methods December
available to all staff on an Can provide evidence of their work if
annual basis required

Establish a methodology for Development of communal Testing tools from other areas at present, Safety Governance 
auditing the quality of records approach to carry out audit evidence from these tests. & Risk Team
within services which use primarily of electronic records by
or solely electronic records November 2009.
(Dentistry & Pharmacy)
Meet HEAT Target for NHS QIS Visit Completed 23rd & 24th Draft Report received from NHS QIS and Safety Governance

Clinical Governance & Risk February 2010 feedback given to NHS QIS await final & Risk Team
Management Standards report.

Deliver actions for previous NHS Following peer review visit Action plan from asthma standards Asthma Standards

QIS Peer Review Visits: there is an Asthma Group
standards group which
monitors the action plan

23
Challenge
Delivery of exit strategy for
Perinatal Mental Health ICP
Project Manager Post. Ensure a
seamless transfer of
responsibilities across services
after post finishes at end of July
2009.
Further development of the Mental
Health ICPs and full accreditation
from NHS QIS
Action to be taken Evidence Responsibility Status
Following peer review visit Action plan from Dental OOH standards Dental OOH

there is a Dental Out of Steering Group
Hours steering group
which monitors the action
plan
Following peer review visit Action plan from FFN standards Nutritional Care

there is a Food, Fluid & Group
Nutritional care group
which monitors the action
plan
Following peer review visit NHS QIS Learning Disabilities Local Learning 
there is a Learning Report. Disabilities Working
Disabilities working group Minutes of Learning Disabilities working Group
that will develop an action group meeting
plan once the standards Action plan from Learning Disabilities
report has been published standards
Following peer review visit Tayside Improvement Panel standards Acting Head of

each area reports their progress reports Safety, Governance
improvements to the & Risk
Tayside Improvement
panel
Risk Assessment for exit Risk assessment Women & Child

strategy developed and Risk control plans Health Lead
risk control plans in place Minutes from exit strategy meetings
Former project manager
secured for 1 day per
week to continue some of
the work
Finalise content of Generic Minutes from Generic steering group to Mental Health ICP ☺
documentation evidence agreement on documentation and Co-ordinator
Revise variances for the variances agreed for the admission and
Admission & Discharge discharge ICP.
ICP Generic ICP documentation
Begin roll our to the CMHT Spread plans
North Perth using PDSA
Consider content of the
condition specific ICPs
and how these will graft
24
Challenge
Further development of the
organisation’s use of the SMART
system to register, manage and
monitor risks
Ensure all appropriate service
areas have an up to date business
continuity management plan which
has been recently reviewed and
tested
Continue FMEA work with medical
records within Ninewells Hospital
Support learning regarding
Scottish Patient Safety
Programme methodologies as it
spreads into further areas of the
organisation
Action to be taken Evidence Responsibility Status
with the generic ICP
Spread plan developed for
roll out into Dundee and
Angus CMHT
Spread plan developed for
roll out into Psychiatry of
Old Age
Utilise the existing data Clinical Dashboard Test Acting Head of ☺
systems available to report Corporate Risk Control Plan Safety Governance
back to service areas what & Risk
they want.
Testing is currently
underway in several areas
Progress and actions are Copies of minutes and papers that are Business Continuity ☺
monitored through the presented at these committees & Emergency
Emergency Planning Planning
Advisory Group (EPAG),
Board Executive Team
and the Delivery Unit
Risk/Health and Safety
Management Group
Action plan for emergency admissions Secondary Care

Develop action plan based Completed FMEA tool Clinical
on the FMEA tool for Governance Co-
emergency admissions Short life working group established to test ordinator
Monitor actions to reduce “Hub” approach to Ombudsman ☺
the risk recommendations regarding medical
records.
Monthly Patient Safety Training materials used Patient Safety

Awareness sessions are Numbers of staff attending training session Development
provided by the Safety Training records Manager
Governance and Risk
team which include
improvement
methodology, using data
at the frontline and
highlight local patient
25
Challenge
Continue to build capacity to
support the SPSP as it spreads
across the organisation
Identify key clinical leads for
spreading the programme
Maintaining the momentum
created by the Patient Safety in
Primary Care Pilot
Action to be taken Evidence Responsibility Status
safety stories
The Safety Governance
and Risk Team also
provide additional training
on request from areas e.g.
SBAR, PVC Bundle
The monthly awareness Numbers attending training session Patient Safety

session are helping with Development
building capacity within the Manager
organisation
The clinical governance
teams and the wider safety
governance risk team
provide training and
support to teams across
the organisation
An additional 50 NHS
Tayside employees
attended the capacity
building event held by the
National Programme
Key clinical leads will be Executive Sponsors Patient Safety

identified following the re- Development
structure of the Manager
organisation
Executive sponsors have
been allocated to each
workstream
Funding from NHS QIS External evaluation from Stirling University Acting Head of

has been secured to link regarding the Pilot Safety Governance
this pilot project with the Correspondence between NHS QIS and & Risk
Scottish Patient Safety NHS Tayside regarding funding
Programme Project Proposal forms to Health
Proposal through to Foundation
second round of Health
Foundation funding
process
26
Challenge Action to be taken Evidence Responsibility Status
Reporting mechanism has Quarterly reports from citizen’s advice Safety Governance

been finalised following bureau staff (developed by NHS Tayside & Risk Team / PFPI
pilot period and was staff) team
Continue to support the Citizen’s commenced at the start of Minutes of the stakeholders meeting
Advice Bureau staff to report on this financial year (April Service Level Agreement and any changes
their activity as per the Service 2009)
Level Agreement with NHS An annual review between
Tayside the key stakeholders is
arranged for July to review
the service level
agreement
Policy has been Policy available on Staffnet and staff aware Secondary Care ☺
developed, with wide of, and using, Policy Clinical
consultation and Governance Co-
involvement. Awareness ordinator /
Develop an Interpretation and raising sessions continue Interpretation &
Translation Policy with staff. Final Translation Project
dissemination in line with Manager
implementation plan
planned for September
2009
Publicise the Service User
Service User Toolkit available on Staffnet. Secondary Care

Final copy of toolkit distributed and minuted Clinical
Feedback Toolkit to ensure staff Toolkit finalised
at three CHP clinical governance Forums Governance Co-
are aware of it
and Secondary Care Forum and TIN. ordinator
Evaluation sheet available Evaluation sheets completed and Secondary Care

Evaluate the use of the service in toolkit. Test completion improvements made to toolkit based on Clinical
user feedback toolkit and usefulness of evaluation. Governance Co-
evaluation sheet ordinator
Continue to spread implementation Complete spread plan
Secondary Care

Clinical
of “How are we doing” across SDU SDU Spread Plan
Governance Co-
questionnaire
ordinator

27
Challenge Action to be taken Evidence Responsibility Status
Mental Health Acute In-

patient forum agreed this
questionnaire to be used Mental Health Acute In Patient Forum
in all functional in-patient Minutes
wards across mental
Safety Governance
health services ☺
& Risk Team
Spread plan to be
developed to support
implementation within Mental Health spread plan
mental health

Specific focus on engaging ☺

with: Posters of You Said we Did and
• elderly population Opinionmeter displayed at NHS Scotland
• Learning event Glasgow.
Engaging and gaining feedback
disabilities those Local engagement evidenced in clinical Safety Governance
from all service users including
with an organic group clinical governance annual reporting. & Risk Team
children and young people
illness e.g. Youth Talkin Forum
dementia Testing of How are We Doing? in
• Children and young Psychiatry of Old Age
people
Project Board to be

established to discuss first
steps of Better Together.
Strategic links to be made
Acting Head of
with this programme and
Implementing Better Together Minutes from Project Board Meetings Safety, Governance
others across the
& Risk
organisation to deliver a
strategic approach to
patient experience and
PFPI

Implementation Status Implementation Status

Action completed  Little or no progress achieved
☺ Action on course for completion  Change to action originally planned
28
 Progress made but slippage on planned

Further information required
timescale

29