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

Annex A: Terms of Reference for the Oversight Board and its Subgroups

Oversight Board

Authority

The Oversight Board for the Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children (RHC), NHS GGC (hereinafter, "the Oversight Board") is convened at the direction of the Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland (NHS Scotland), further to his letter of 22 November 2019 to the Chairman and Chief Executive of NHS GGC. These terms of reference have been set by the Director General, further to consultation with the members of the Oversight Board.

Purpose and Role

The purpose of the Oversight Board is to support NHS GGC in determining what steps are necessary to ensure the delivery of and increase public confidence in safe, accessible, high-quality, person-centred care at the QEUH and RHC, and to advise the Director General that such steps have been taken. In particular, the Oversight Board will seek to:

• ensure appropriate governance is in place in relation to infection prevention, management and control;
• strengthen practice to mitigate avoidable harms, particularly with respect to infection prevention, management and control;
• improve how families with children being cared for or monitored by the haemato-oncology service have received relevant information and been engaged with;
• confirm that relevant environments at the QEUH and RHC are and continue to be safe;
• oversee and consider recommendations for action further to the review of relevant cases, including cases of infection;
• provide oversight on connected issues that emerge;
• consider the lessons learned that could be shared across NHS Scotland; and
• provide advice to the Director General about potential de-escalation of the NHS GGC Board from Stage 4.

Background

In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement issues, the Director General for Health and Social Care and Chief Executive of NHS Scotland has concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and therefore that for this specific issue the Board will be escalated to Stage 4 of the Performance Framework. This stage is defined as 'significant risks to delivery, quality, financial performance or safety; senior level external transformational support required'.

Approach

The Oversight Board will agree a programme of work to pursue the objectives described above. In this, it will establish subgroups with necessary experts and other participants. The remit of the subgroups will be set by the chair of the Oversight Board, in consultation with Board members. The Board will receive reports and consider recommendations from the subgroups.

In line with the NHS Scotland escalation process, NHS GGC will work with the Oversight Board to construct required plans and to take responsibility for delivery. The NHS GGC Chief Executive as Accountable Officer continues to be responsible for matters of resource allocation connected to delivering actions agreed by the Oversight Board.

The Oversight Board will take a values-based approach in line with the Scottish Government's overarching National Performance Framework (NPF) and the values of NHS Scotland.

The NPF values inform the behaviours people in Scotland should see in everyday life, forming part of our commitment to improving individual and collective wellbeing, and will inform the behaviours of the Oversight Board individually and collectively:

• to treat all our people with kindness, dignity and compassion;
• to respect the rule of law; and
• to act in an open and transparent way.

The values of NHS Scotland are:

• care and compassion;
• dignity and respect;
• openness, honesty and responsibility; and
• quality and teamwork.

The Oversight Board Members will endeavour to adopt the NPF and NHS Scotland values in their delivery of their work and in their interaction with all stakeholders.

The OB's work will also be informed by engagement work undertaken with other stakeholder groups, in particular family members/patient representatives and also NHS GGC staff.

The Oversight Board is focused on improvement. Oversight Board members, and subgroup members, will ensure a lessons-learned approach underpins their work in order that learning is captured and shared locally and nationally.

Meetings

The Oversight Board will meet weekly for the first four weeks and thereafter meet fortnightly. Video-conferencing and tele-conferencing will be provided.

Full administrative support will be provided by officials from CNOD. The circulation list for meeting details/agendas/papers/action notes will comprise Oversight Board members, their Personal Assistants and relevant CNOD staff. The Chairman and Chief Executive of NHS Greater Glasgow and Clyde will also receive copies of the papers.

Objectives, Deliverables and Milestones

The objectives for the Oversight Board are to:

• improve the provision of responses, information and support to patients and their families;
• if identified, support any improvements in the delivery of effective governance and assurance within the Directorates identified;
• provide specific support for infection prevention and control, if required;
• provide specific support for communication and engagement; and
• oversee progress on the refurbishment of Wards 2A/B and any related estates and facilities issues as they pertain to haemato-oncology services.

Matters that are not related to the issues that gave rise to escalation are assumed not to be in scope, unless Oversight Board work establishes a significant link to the issues set out above.

In order to meet these objectives, the Oversight Board will retrospectively assess issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement; having identified these issues, produce a gap analysis and work with NHS GGC to seek assurance that they have already been resolved or that action is being taken to resolve them; compare systems, processes and governance with national standards, and make recommendations for improvement and how to share lessons learned across NHS Scotland. The issues will be assessed with regards to the information available at the particular point in time and relevant standards that were extant at that point in time. Consideration will also be given to any subsequent information or knowledge gained from further investigations and the lessons learned reported.

Governance

The Oversight Board will be chaired by the Chief Nursing Officer, Professor Fiona McQueen, and will report to the Director General for Health and Social Care.

Membership

Member, Job Title

• Professor Fiona McQueen (Chair), Chief Nursing Officer, Scottish Government
• Keith Morris (Deputy Chair), Medical Advisor, Chief Nursing Officer's Directorate (CNOD), Scottish Government
• Professor Hazel Borland, Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran
• Professor Craig White, Divisional Clinical Lead, Healthcare Quality and Improvement Directorate, Scottish Government
• Dr Andrew Murray, Medical Director, NHS Forth Valley and Co-chair of Managed Service Network for Children and Young People with Cancer (MSN CYPC)
• Professor John Cuddihy, Families representative
• Lesley Shepherd, Professional Advisor, CNOD, Scottish Government
• Alan Morrison, Health Finance Directorate, Scottish Government
• Sandra Aitkenhead, CNOD, Scottish Government (secondee)
• Greig Chalmers, Interim Deputy Director, CNOD, Scottish Government
• Jim Dryden/Carole Campariol-Scott/Calum Henderson/Phil Raines (Secretariat), CNOD, Scottish Government

The Co-chair of Area Partnership Forum and the Chair of the Area Clinical Forum will be in attendance at the meetings. In addition to these members, other attendees may be present at meetings based on agenda items, as observers: senior executives and Board Members from NHS GGC including, Medical Director, Nurse Director, Director of Estates and Facilities, Director of Communications, Board Chair and Chief Executive; and representatives from HPS, HFS, HIS, HEI and HSE.

Stakeholders

The Oversight Board recognises that a broad range of stakeholder groups have an interest in their work, and will seek to ensure their views are represented and considered. These stakeholders include:

• patients, service users and their families;
• the general public;
• the Scottish Parliament;
• the Scottish Government, particularly the Health and Social Care Management Board;
• the Board of NHS GGC and the senior leadership team of NHS GGC; and
• the staff of NHS GGC and Trade Unions.

Special focus will be given to patients of the haemato-oncology service and their families, as highlighted by their direct involvement in the Communication and Engagement Subgroup.

Infection Prevention and Control, and Governance Subgroup

Purpose and Role

The Infection Prevention and Control Governance (IPCG) Subgroup for the NHS GGC Scottish Government Oversight Board is a time-limited group which has been convened to work with NHS GGC to:

• determine whether appropriate Infection Prevention and Control Governance is in place across the organisation to increase public confidence; and
• make recommendations, if required and where appropriate, to strengthen current approaches to mitigate avoidable infection harms

The IPCG Subgroup directly reports to the Oversight Board, which is chaired by the Chief Nursing Officer, Professor Fiona McQueen. It has specific responsibilities for supporting the Oversight Board to ensure, where necessary and appropriate, improvements are made in the delivery of effective governance and provide assurance relating to infection prevention and control within and across NHS GGC.

Background

In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement issues, the Director General for Health and Social Care and Chief Executive of NHS Scotland has concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and, therefore, that for this specific issue the Board was escalated to Stage 4 of the performance framework. This stage is defined as 'significant risks to delivery, quality, financial performance or safety; senior level external transformational support required.'

The IPCG Subgroup will focus on issues relating to infection prevention and control and associated governance that gave rise to escalation to Stage 4.

Approach

The IPCG Subgroup will take a values based approach in line with NPF and the values of NHS Scotland.

The NPF values inform the behaviours people in Scotland should see in everyday life, forming part of our commitment to improving individual and collective wellbeing, and will inform the behaviours of the Oversight Board individually and collectively:

• to treat all our people with kindness, dignity and compassion;
• to respect the rule of law; and
• to act in an open and transparent way.

The values of NHS Scotland are:

• care and compassion;
• dignity and respect;
• openness, honesty and responsibility; and
• quality and teamwork.

These values will be embedded in the work of the IPCG Subgroup and will be informed by engagement work undertaken with key stakeholder groups.

The Subgroup is focused on improvement and as such the Subgroup members will ensure an evidence based, risk based, lessons-learned approach underpins their work in order that assurance can be articulated and learning is captured and shared both locally and nationally.

Meetings

The Subgroup will meet frequently for the first four weeks, with frequency thereafter to be determined as required. Video-conferencing or tele-conferencing will be provided.

Full administrative support will be provided by officials from CNOD. The circulation list for meeting details/agendas/papers/action notes will comprise Subgroup members, their PAs and relevant CNOD staff.

Objectives

The objectives for the Subgroup are to:

• carry out a system wide review of current systems and processes relating to the infection prevention and control and associated governance scheme of delegation and escalation mechanisms against relevant national standards and guidance;
• 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;
• provide support to the IPC Team within NHS GGC in the identification of measures for assurance as part of the review process and for future improvement/implementation; and
• make recommendations where appropriate to the Oversight Board on areas of learning for other Health Boards

In Scope

In order to meet these objectives, the Subgroup will retrospectively assess systems, processes and governance arrangements in relation to IPC management and control across the whole of NHS GGC. It will do so by reviewing:

• alignment of IPC and wider Board structures within the span of influence of NHS GGC; and
• a range of reports considered by the Board Corporate Governance Committees and the network of Operational Governance Groups and Committees including those reports presented to the associate Integrated Joint Boards.

Deliverables will be agreed in the early meetings of the Subgroup and with the Oversight Board.

Out of Scope

The Subgroup will not review:

• roles and responsibilities of individual staff members within NHS GGC; and
• aspects covered by either the Communication and Engagement or Technical Subgroups of the Oversight Board.

Governance

The Subgroup will be chaired by Diane Murray, and will report to the Chair of the Oversight Board.

Member, Job Title

• Diane Murray (Chair), Deputy Chief Nursing Officer, Scottish Government
• Hazel Borland , Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran
• Professor Angela Wallace, Nurse Director, NHS Forth Valley
• Professor Craig White, Divisional Clinical Lead, Healthcare Quality and Improvement Directorate, Scottish Government
• Frances Lafferty, Infection Control Nurse, NHS Ayrshire and Arran
• Martin Connor, Infection Control Doctor, NHS Dumfries and Galloway
• Helen Buchanan, Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Fife
• Christina Coulombe, Infection Control Manager, NHS Lanarkshire
• Lisa Ritchie, Nurse Consultant, Health Protection Scotland, NHS National Services Scotland
• Professor Marion Bain, Director for Infection Prevention and Control, NHS GGC (secondee)
• Phil Raines, Chief Nursing Officer's Directorate (CNOD), Scottish Government
• Sandra Aitkenhead, CNOD, Scottish Government (secondee)
• Lesley Shepherd, Professional Nurse Advisor, CNOD, Scottish Government
• Jim Dryden/Carole Campariol-Scott/Calum Henderson (Secretariat), CNOD, Scottish Government

Associated Participant, Job Title

• Sandra Devine, Infection Control Manager, NHS GGC
• Pamela Joannidis, Infection Control Nurse, NHS GGC
• Dr. A Leonard, Infection Control Doctor, NHS GGC
• Dr. J Armstrong, Medical Director, NHS GGC
• Elaine Vanhegan, NHS GGC Board Governance Lead

NHS GGC may have other officers in attendance dependant on the issue being discussed and agreed through the chair.

Technical Issues Subgroup

Authority

The Oversight Board for the QEUH and RHC, NHS GGC has been established at the direction of the Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland, further to his letter of 22 November 2019 to the Chairman and Chief Executive of NHS GGC.

A technical subgroup of the Oversight Board has been established to provide technical review, advice and assurance on the relevant technical matters relating to the built environment of the hospitals.

Purpose and Objectives

The purpose of the Technical Subgroup is to support the work of the Oversight Board, with a particular focus on the technical workings of the hospitals and any related technical reviews or reports. In particular the Technical Subgroup will:

• confirm that relevant environments at the QEUH and the RHC are and continue to be safe;
• oversee progress on the refurbishment and reopening of Wards 2A/B at the RHC and any related estates and facilities issues as they pertain to haemato-oncology services, such as Ward 6A at the QEUH;
• ensure that there are appropriate action plans in place to address any technical issues highlighted by competent authorities such as the Health and Safety Executive, Health Protection Scotland or Health Facilities Scotland and that these action plans are being delivered and provide oversight on connected issues that emerge;
• consider the lessons learned that could be shared across NHS Scotland; and
• provide advice to Oversight Board about potential de-escalation of the NHS GGC Board from Stage 4, in relation to these issues.

Background

In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement issues, the Director General for Health and Social Care and Chief Executive of NHS Scotland has concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and therefore that for this specific issue the Board will be escalated to Stage 4 of the Performance Framework. This stage is defined as 'significant risks to delivery, quality, financial performance or safety; senior level external transformational support required'.

Approach

The Oversight Board is required to establish subgroups with necessary experts and other participants; this subgroup will address the requirement to ensure that relevant environments at the QEUH and RHC are and continue to be safe. To ensure delivery of that overarching objective, the Technical Subgroup will agree a programme of work to ensure that it complies with the purpose and objectives of the group described above.

The Oversight Board, and its subgroups, is focused on improvement. Members of this subgroup, will ensure a lessons-learned approach underpins their work in order that learning is captured and shared locally and nationally.

Meetings

The Technical Subgroup will meet every three weeks, but if necessary more regular meetings will be arranged.

Full administrative support will be provided by officials from CNOD in the Scottish Government.

Governance/Accountability

The Subgroup will be chaired by the Alan Morrison, Health Finance and Infrastructure, Scottish Government and will report direct to the Oversight Board.

Membership

Member, Job Title

• Alan Morrison (Chair), Health Finance Directorate, Scottish Government
• Tom Steele, Director of Estates, NHS Greater Glasgow and Clyde
• Gerry Cox, Deputy Director of Estates, NHS Greater Glasgow and Clyde
• Ian Storrar, Principal Engineer, Health Facilities Scotland
• Lisa Ritchie , Nurse Consultant, Health Protection Scotland, NHS National Services Scotland
• Sandra Aitkenhead, Chief Nursing Officers Directorate (CNOD), Scottish Government (secondee)
• Phil Raines, CNOD, Scottish Government
• Calum Henderson (Secretariat), CNOD, Scottish Government

Additional involvement will be requested as necessary.

Communication and Engagement Subgroup

Purpose and Role

The Communication and Engagement Subgroup the QEUH and the RHC, NHS GGC, is a time limited group to offer advice and assurance working with Scottish Government and NHS GGC on:

• effective communication and engagement with patients and families; and
• robust, consistent and reliable person-centred engagement and communication.

Background

In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement issues, the Director General for Health and Social Care and Chief Executive of NHS Scotland has concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and therefore that for this specific issue the Board will be escalated to Stage 4 of the performance framework. This stage is defined as 'significant risks to delivery, quality, financial performance or safety; senior level external transformational support required.'

Approach

The Communication and Engagement Subgroup will take a values based approach in line with the NPF and the values of NHS Scotland. The NPF values inform the behaviours people in Scotland should see in everyday life, forming part of our commitment to improving individual and collective wellbeing, and will inform the work of the Subgroup individually and collectively:

• to treat all our people with kindness, dignity and compassion;
• to respect the rule of law; and
• to act in an open and transparent way.

The values of NHS Scotland are:

• care and compassion;
• dignity and respect;
• openness, honesty and responsibility; and
• quality and teamwork.

These values will be embedded in the work of the Communication and Engagement Subgroup, and this work will also be informed by engagement work undertaken with other stakeholder groups, in particular family members/patient representatives, respecting the importance of specific values informed actions linked to personal context and experiences.

The Communication and Engagement Subgroup is focused on improvement. Subgroup members, will ensure a 'lessons learned' approach, as well as respecting the experience of families must underpin and inform the identification of improvements for dissemination both locally and nationally.

Meetings

The Communication and Engagement Subgroup will meet fortnightly initially and then at a frequency to be determined thereafter. Tele-conferencing will be provided.

A range of communication and engagement mechanisms will be agreed to enable patients and families to feed into the work of the Communication and Engagement Subgroup.

Full administrative support will be provided by officials from Scottish Government. The circulation list for meeting details/agendas/papers/action notes will comprise Oversight Board members, their PAs and relevant CNOD staff.

Outcomes

The Outcomes for the Communication and Engagement Subgroup are to:

• positively impact on patients and their families in relation to how complex infection control issues and all related matters are identified, managed and communicated;
• demonstrate a proactive approach to engagement, communication and the provision of information; and
• identify what has worked well and where the provision of information, communication and engagement could have been and could be enhanced and improved.to ensure that the outputs from the group are disseminated to key stakeholders and any wider learning points or recommendations are shared nationally.

In order to achieve these outcomes, the Communication and Engagement Subgroup will retrospectively assess factors influencing the approach to communication and public engagement associated with the infection prevention and control issues and related matters at the QEUH and RHC.

Having identified these issues, the Subgroup will work with NHS GGC to seek assurance that they have already been resolved or that action is being taken to resolve them; compare systems, processes and governance with national standards, and make recommendations for improvement and good practice as well as lessons learned across NHS Scotland.

Deliverables

The Deliverables for the Communication and Engagement Subgroup are:

• a prioritised description of communication and information to be provided to families, with a focus on respect and transparency (with an initial focus on ensuring that all outstanding patient and family questions raised are answered);
• development of a strategic Communication and Engagement Plan with a person-centred approach as key. This should link to and be informed by consideration of existing person-centred care and engagement work within the Board, to ensure continued strong links between families and NHS GGC. Specific enhancements and improvement proposals should also be clearly identified and should consider how the proposals from parent representatives on an approach that identifies and supports the delivery of personalised actions through the 'PACT' proposal can inform further work;
• a description of findings following a review of materials, policies and procedures in respect of existing practices with regards to communication, engagement and decision-making arising from corporate and operational communication and engagement, linked to infection prevention and control and related issues. This will include consideration of organisational duty of candour, significant clinical incident reviews, supported access to medical records (including engagement, involvement and provision of information to families in relation to these processes); and
• a description of findings and recommendations to: (a) NHS GGC; (b) Health Protection Scotland; (c) NHS Scotland; and (d) Scottish Government on learning to support any required changes and improvements for communication and public engagement relating to the matters considered by the Subgroup.

Governance

The Communication and Engagement Subgroup will be chaired by Professor Craig White, and will report to the Oversight Board. The Oversight Board is chaired by the Chief Nursing Officer, Scottish Government and reports to the Cabinet Secretary for Health and Sport. Members and those present at Subgroup meetings should ensure that they circulate information about the work of the Subgroup to colleagues and networks with an interest, contribution and perspective that can inform the work to be undertaken. This must include clinical and care staff within relevant operational services, as well as senior management and corporate staff within NHS GGC.

Membership

Member, Job Title

• Professor Craig White (Chair). Divisional Clinical Lead, Healthcare Quality and Improvement Directorate, Scottish Government
• Lynsey Cleland, Director of Community Engagement, Healthcare Improvement Scotland
• Andrew Moore, Head of Excellence in Care, Healthcare Improvement Scotland
• Professor Angela Wallace, Nursing Director, NHS Forth Valley
• Jane Duncan, Director of Communications, NHS Tayside
• Professor John Cuddihy, Families representative
• Suzanne Hart, Communication, Scottish Government
• Phil Raines, Chief Nursing Officer's Directorate (CNOD), Scottish Government
• Jim Dryden / Calum Henderson (Secretariat), CNOD, Scottish Government

In addition to these members, other attendees may be present at meetings based on agenda items, for example: Chair of Infection Prevention and Control and Governance subgroup; relevant Directors and senior staff from NHS GGC and communication staff from Scottish Government.

Stakeholders

The Communication and Engagement Subgroup recognise that a broad range of stakeholder groups have an interest in their work, and will seek to ensure their views are represented and considered. These stakeholders include:

• patients and their families;
• the general public;
• the Scottish Parliament;
• Scottish Government, particularly the Health and Social Care Management Board;
• the staff of NHS GGC, Trade Unions and professional bodies; and
• the senior leadership team of NHS GGC and the Board.