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

Governance and Risk Management

88. The second set of escalation issues which the Oversight Board is examining is IPC governance. Its importance has been captured in the Blueprint for Good Governance for NHS Scotland^[12], which sets out key principles Health Boards should embody, including the ability to:

• identify current and future corporate, clinical, legislative, financial and reputational risks; and
• oversee an effective risk management system that assesses level of risk, identifies mitigation and provides assurance that risk is being effectively treated, tolerated or eliminated.

This is supplemented by the descriptions of good governance and the approach all Health Boards should take towards quality planning and management in key documents by HIS^[13].

89. With respect to IPC, that covers a range of important areas, such as the way in which infection incidents and corresponding actions have been escalated, scrutinised, endorsed and monitored by the governance structure within a Health Board. It also includes how IPC and associated risks are identified, reviewed and overseen by relevant Committees (as well as the Board itself). Consequently, the Oversight Board is reviewing in detail:

• how infection incidents from 2015 onwards were identified and escalated through the governance structures of NHS GGC;
• how risk management was used and adopted accordingly,
• how well the relevant Committees and groups provided direction, monitoring, scrutiny and assurance about the handling of individual incidents, the way in which staff responded, how people were kept informed about what was happening, any weaknesses identified in the building/environment as a result, and the actions taken to address those weaknesses and prevent further problems in future; and
• the overall leadership shown in acting effectively in response and with foresight in dealing with the complicated challenges highlighted by the building.

Progress Update

90. Assessment of these issues has also been led by the IPCG Subgroup for the Oversight Board. This includes the following specially-commissioned work:

• a 'timeline' of infections and the Health Board's responses between 2015 and 2019;
• detailed analysis of the minutes and papers of the IMTs, various groups and Committees about how the issues were reported, escalated, actioned and reviewed within the governance structure; and
• a specific peer review of IPC governance, taking account of the recent changes introduced within the Health Board following the appointments of Professors Bain and Wallace.

91. All of this work is still to be finalised so the Oversight Board will set out its findings and recommendations on IPC Governance in the Final Report.