Publication - Corporate report

Queen Elizabeth University Hospital/ NHS Greater Glasgow and Clyde Oversight Board: final report

The Final Report of the Queen Elizabeth University Hospital Oversight Board sets out findings and recommendations in relation to the escalation of NHS Greater Glasgow and Clyde to Stage 4 of the NHS Scotland performance framework for reasons of infection control and governance in the Health Board.

127 page PDF

918.4 kB

127 page PDF

918.4 kB

Contents
Queen Elizabeth University Hospital/ NHS Greater Glasgow and Clyde Oversight Board: final report
Annex D: Key Success Indicators of the Oversight Board

127 page PDF

918.4 kB

Annex D: Key Success Indicators of the Oversight Board

Outcome Action Example of Evidence
Infection Prevention and Control and Governance
There is appropriate governance for infection prevention and control (IPC) in place to provide assurance on the safe, effective and person-centred delivery of care and increase public confidence. Carry out a system wide review of current IPC systems and processes and associated governance scheme of delegation and escalation mechanisms against relevant national standards and guidance.
  • Confirmation of current/sustainable effective governance with respect to: HAIRT Reports; Clinical and Care Governance Committee and Audit and Risk Committee Reports; AOP and Corporate Objectives and Performance Reports; IPC Inspection and Escalation Reports; IPC Audit Reports and Action Plans; relevant Antimicrobial Management/ Infection Control/ Decontamination/ Water Safety/ Education and Training/ Surveillance/ Outbreak Preparedness and Management/ Audits/ Policy and Procedures/ Inspection and Action Plans/ IPC Escalation Reports/ SBARs/ Research and Development and Voluntary Action Plan Updates; and IPC Risks.
  • Active action plans to address recommendations/action on relevant HPS/ HEI/ Internal reports since 2015 with clear timelines, monitoring, action responsibility and appropriate oversight.
Determine if there are any gaps when mapped against national standards and guidance and, if so, identify areas for improvement and shared learning with respect to IPC risk management, audit, performance, compliance and assurance.
  • Report setting out gaps in national standards/guidance and provision of NHS GGC action plan to address issues and monitoring arrangements for action plan.
  • Report setting out wider learning with regards to IPC risk management, audit, performance, compliance and assurance for consideration by DG Health and Social Care, SG Ministers, and NHS Chairs and NHS Chief Executives fora (as part of wider Oversight Board reporting).
The current approaches that are in place to mitigate avoidable harms, with respect to infection prevention and control, are sufficient to deliver safe, effective and person-centred care. Conduct a detailed review of relevant individual instances of infection and identify actions on individual cases and systemic improvements.
  • Clear methodology for identifying and undertaking review of all relevant cases, validated by external experts.
  • Identification of general issues relating to the IPC governance issues and provision of NHS GGC action plan to address issues and monitoring arrangements for action plan.
  • Identification of individual issues relating to specific cases and NHS GGC action plan to communicate and engage with relevant families/patients and monitoring arrangements for action plan.
Ensure that the physical environment to the relevant wards in QEUH and RHC support the delivery of safe, effective and person-centred care with respect IPC, particularly in the delivery of any refurbishments/physical improvements.
  • Action plan setting out identification of key issues in Ward 6A in QEUH and implementation of how they have been dealt with.
  • Assessment setting out completion of refurbishment works in Wards 2A/2B in RHC and how identified issues were addressed.
  • Confirmation of action plan and assessment above by HPS.
Determine if there are any gaps when mapped against national standards and guidance and, if so, identify areas for improvement and shared learning with respect to operational delivery of IPC, including staffing/ resourcing, minimum skills and joint working between relevant units.
  • Evidence of full implementation of mandatory national HCAI and AMR policy requirements as set out in DL (2019) 23.
  • NHS GGC action plan to identify staffing/ resourcing gaps in IPC operations with respect to putting in place policy requirements in DL (2019) 23, address the identified gaps with clear actions/ timetables and monitoring arrangements for delivery.
Communication and Engagement
Families and children and young people within the haemato-oncology service receive relevant information and are engaged with in a manner that reflects the values of NHS Scotland (NHSS) in full. Prioritise communication and information provided to families and patients with a focus on respect and transparency (with an initial focus on ensuring that all outstanding patient and family questions raised are answered).
  • Compilation of outstanding questions by families and publication of responses on NHS GGC website.
  • Published process for responding to questions in future as part of NHS GGC Communication strategy.
  • All additions/revisions/updates to questions previously answered have been made as soon as additional information has been received and/or reviewed.
Families and children and young people within the haemato-oncology service are treated with respect to their rights to information and participation in a culture reflecting the values of the NHSS in full. Develop and implement a strategic NHS GGC Communication strategy with a person-centred approach, including a clear Executive Lead for implementing and monitoring.
  • Publication of relevant NHS GGC Communication strategy with evidence of co-production with families.
  • Identification of Executive Lead to implement strategy with monitoring arrangements and measures of implementation and measures of effectiveness in place.
Review key materials, policies and procedures in respect of existing practices with regards to communication, engagement and decision-making regarding consideration of the organisational duty of candour similar reviews (including engagement, involvement and provision of information to families in relation to these processes), and identification of any national learning/ lessons learnt.
  • Report setting out gaps in compliance, opportunities for improvement, recommendations for action and provision of NHS GGC action plan to address issues and monitoring arrangements for action plan.
  • Identification of individual issues relating to specific cases and NHS GGC action plan to communicate and engage with relevant families/patients.
  • Reporting setting out wider learning with regards to organisational duty of candour and other review processes and management of IPC activities for consideration by DG Health and Social Care, SG Ministers, and NHS Chairs and NHS Chief Executives fora (as part of wider Oversight Board reporting).
  • Clear description of how communication, engagement, information provision and support dimensions of Oversight Board case reviews will integrate family involvement and engagement in accordance with best practice case reviews and individual family preferences.

Contact

Email: philip.raines@gov.scot