Clinical Governance Meeting Note (custom)

Clinician Specialty: Practice Manager Clinical Governance Meeting Minutes 1. Meeting Details: Organisation or department hosting the meeting: "Evergreen Medical Centre Clinical Governance Committee" Date: 01 November 2024 Time: 10:00 AM - 12:00 PM Location: Main Conference Room, Evergreen Medical Centre Chair: Sarah Jenkins, Practice Manager Attendees: Dr. Eleanor Vance, Lead GP Dr. David Chen, Senior GP Nurse Manager Emily White Practice Administrator Mark Davies Apologies: Dr. Robert Allen, GP Partner Quorum Status: Quorum was achieved as per the committee's constitution, which requires a minimum of three clinical staff and one administrative staff member. Four out of five required members were present, including the Chair. 2. Previous Minutes: Confirmation of Previous Minutes: The minutes from the meeting held on 01 October 2024 were accepted as a true and accurate record. Dr. Vance moved the motion, and Nurse Manager White seconded it. Matters Arising: Review of Patient Feedback System: Mark Davies, Ongoing, Integration with new CRM system in progress, target completion 15 November 2024. Mandatory Staff Training Compliance: Sarah Jenkins, Complete, 95% compliance achieved, follow-up planned for remaining 5%. 3. Incident Review: Summary of Incidents Since Last Meeting: A total of 5 incidents were reported since the previous meeting. This included 2 'minor harm' incidents (patient falls) and 3 'no harm' incidents (medication errors caught prior to administration, administrative error). The primary categories involved patient safety and medication management. Specific Incidents for Detailed Discussion: Incident 2024-005 (Patient Fall): A 78-year-old male patient fell while awaiting a consultation in the waiting room. Contributing factors included insufficient clear signage indicating slippery floor after cleaning and the patient's existing mobility issues. Immediate actions included reviewing cleaning protocols and placing temporary 'wet floor' signs. Impact was minor bruising and a slight delay in consultation. Incident 2024-006 (Medication Error - Admin): A prescription for amoxicillin was incorrectly entered as 500mg instead of 250mg for a paediatric patient. The error was identified by the dispensing pharmacist during their double-check. Contributing factors included a busy clinic environment and a new administrative staff member. Impact was mitigated by the pharmacist's check, preventing harm. Root Cause Analyses: Incident 2024-005 (Patient Fall): RCA completed. Findings highlighted the need for improved communication between cleaning staff and reception, and the implementation of non-slip mats in high-traffic areas during wet conditions. Recommendations include a review of waiting room safety protocols and staff training on incident reporting. Trends Identified: There is a notable trend in patient falls occurring within the waiting room environment, particularly during peak hours or after cleaning. Two incidents have occurred in the last quarter. This suggests a systemic issue related to environmental safety and patient supervision. Recommendations Arising: Implement a formal 'wet floor' signage policy and protocol for cleaning staff – Responsible Person: Mark Davies. Review waiting room layout and consider non-slip flooring or mats – Responsible Person: Sarah Jenkins. Develop a specific training module on medication prescription entry for all administrative staff – Responsible Person: Nurse Manager Emily White. 4. Clinical Audit and Quality Indicators: Audit Results Presented: Audit: "Diabetes Management in Primary Care (Q3 2024)". Scope: Review of 100 patient records with Type 2 Diabetes. Methodology: Retrospective chart review against NICE guidelines. Key findings: 85% of patients had annual foot checks documented, 70% had HbA1c within target, 60% had regular eye screening referrals. Conclusions: Good compliance with basic checks, but areas for improvement in HbA1c control and eye screening follow-up. Performance Against Benchmarks: Performance against the national benchmark for mandatory staff training compliance (90%) was met at 95%. Performance against the QOF target for HbA1c control (75%) was not met, achieving 70%. Areas of Concern: The audit indicated a shortfall in achieving target HbA1c levels for diabetic patients, with only 70% meeting the target. Contributing factors may include patient adherence, medication optimisation, and frequency of follow-up. Proposed corrective actions include a dedicated diabetes clinic and patient education sessions. Areas of Good Practice: The practice demonstrated excellent compliance with annual foot checks for diabetic patients (85%), showcasing a strong commitment to preventative care in this area. 5. Risk Register Review: New Risks Identified: Risk: "Data Breach due to Inadequate Cybersecurity Measures". Initial Risk Rating: High. Proposed Controls: Implement multi-factor authentication, regular staff training on data security, conduct external penetration testing. Responsible Person: Mark Davies. Existing Risks Reviewed: Risk: "Staff Burnout due to High Workload". Current Risk Rating: Medium (previously High). Controls in place: Implemented flexible working arrangements, introduced wellbeing initiatives, hired new administrative support. Effectiveness: Controls are moderately effective, risk rating reduced due to recent improvements. Further actions required: Monitor staff feedback, consider further recruitment for clinical roles. Risks for Escalation: Risk: "Funding Shortfall for New Diagnostic Equipment". Rationale for escalation: This significantly impacts the ability to provide timely and accurate diagnoses, potentially affecting patient outcomes and practice reputation. Requires board-level discussion for budget allocation. Risks Recommended for Closure: Risk: "Outdated Patient Information Leaflets". Rationale: All patient information leaflets have been reviewed, updated, and uploaded to the practice website, with hard copies made available. 6. Policy and Guideline Review: Policies Due for Review: "Infection Control Policy", Current Version Date: 01 May 2023, Assigned Reviewer: Nurse Manager Emily White. "Patient Confidentiality Policy", Current Version Date: 01 June 2023, Assigned Reviewer: Dr. Eleanor Vance. New Guidelines to Adopt: "NICE Guideline NG28: Type 2 Diabetes in Adults: Management". Source: National Institute for Health and Care Excellence. Relevance: Direct impact on our diabetes management protocols. Proposed implementation: Integrate into staff training and update clinical pathways. Gaps Identified: A gap exists in the current 'Safeguarding Adults' policy regarding specific protocols for identifying and reporting financial abuse in vulnerable adults. This affects elderly and disabled patients. Proposed actions: Review and update the policy to include clear guidelines and reporting pathways for financial abuse. 7. Compliance and Regulatory: Accreditation Status: The practice maintains 'Good' CQC rating. An unannounced CQC inspection is anticipated within the next 6-12 months. Preparation requirements include a mock inspection and review of all governance documentation. Regulatory Correspondence: Received an information request from NHS England regarding GP access data for Q3 2024. Nature of correspondence: Routine data collection. Required actions: Data submitted on 25 October 2024. Mandatory Reporting Obligations: Notification of a serious incident (patient fall leading to fracture) submitted to CQC on 15 October 2024. Authority: Care Quality Commission. Deadline: N/A, report submitted within 24 hours. External Reviews: A peer review of prescribing practices was conducted by a neighbouring practice on 20 October 2024. Scope: Review of antibiotic prescribing for URTI. Findings: Practice prescribing generally aligned with national guidelines, minor areas for optimisation identified. 8. Consumer Feedback: Patient Complaints and Compliments: Since the last meeting, 3 formal complaints and 7 compliments were received. Key complaint themes: Waiting times (2 complaints), communication with reception staff (1 complaint). Key compliment themes: Doctor's empathy, efficiency of nursing staff. Actions taken: Staff training on communication skills initiated, review of appointment system ongoing. Patient Experience Data: Results from the latest GP Patient Survey (September 2024) were reviewed. Key findings: 80% reported a good overall experience (up from 75%), but 45% found it difficult to get an appointment (no change). Trends: General improvement in patient satisfaction, but appointment access remains a persistent issue. 9. Improvement Initiatives: Current Quality Improvement Projects: Project: "Reducing DNA Appointments". Current Status: Pilot phase in progress. Progress against milestones: Implemented SMS reminders, revised booking system. Outcomes achieved: 15% reduction in DNA rates in pilot group. Lead: Mark Davies. New Initiatives Proposed: Initiative: "Dedicated Diabetes Clinic". Rationale: To improve HbA1c control and provide comprehensive care. Scope: Fortnightly clinic led by Dr. Vance and Nurse Manager White. Proposed Lead: Dr. Eleanor Vance. Resource requirements: Requires additional nursing hours and a dedicated consultation room. 10. Education and Training: Clinical Education Delivered: "Basic Life Support Refresher", Audience: All clinical staff, Attendance: 15. Delivered on 18 October 2024. "New Safeguarding Adults Guidelines", Audience: All staff, Attendance: 20. Delivered on 22 October 2024. Mandatory Training Compliance: Current mandatory training compliance rates stand at 95% for clinical staff and 90% for administrative staff. Areas of concern include fire safety training for new administrative hires. Lessons Learned Communications: "Lessons from Incident 2024-005 (Patient Fall)", Format: Email bulletin and staff meeting discussion, Distribution: All staff, Date: 28 October 2024. "Updated Prescription Protocol", Format: Intranet update and team briefing, Distribution: All clinical and administrative staff involved in prescribing, Date: 29 October 2024. 11. Items for Escalation: Issue: "Funding Shortfall for New Diagnostic Equipment". Rationale: This directly impacts patient care quality and staff efficiency. Recommended action: Present detailed business case to the Board for immediate budget allocation. Urgency: High. Issue: "Persistent Challenges with Patient Access to Appointments". Rationale: Despite improvement initiatives, this remains a significant patient dissatisfier and CQC concern. Recommended action: Request Board support for strategic review of practice capacity and potential expansion. Urgency: Medium. 12. Action Register: Actions Carried Forward from Previous Meetings: Review and update patient communication protocols: Mark Davies, Original Deadline: 15 Oct 2024, Revised Deadline: 08 Nov 2024, Status: In progress. Procure new waiting room chairs: Sarah Jenkins, Original Deadline: 20 Oct 2024, Status: Delayed due to supplier issues, re-quote requested. New Actions from This Meeting: Implement formal 'wet floor' signage policy: Mark Davies, Deadline: 15 Nov 2024, Arising from: Incident Review. Review waiting room layout for safety improvements: Sarah Jenkins, Deadline: 30 Nov 2024, Arising from: Incident Review. Develop dedicated diabetes clinic proposal: Dr. Eleanor Vance, Deadline: 01 Dec 2024, Arising from: Improvement Initiatives. Update 'Safeguarding Adults' policy for financial abuse: Nurse Manager Emily White, Deadline: 22 Nov 2024, Arising from: Policy and Guideline Review. 13. Next Meeting: Date: 01 December 2024 Time: 10:00 AM Standing Agenda Items: Incident Review Clinical Audit and Quality Indicators Risk Register Review Action Register Update Special Agenda Items: Presentation of Diabetes Clinic Proposal (Dr. Vance) Discussion on Board Feedback regarding Diagnostic Equipment Funding (Sarah Jenkins)