TRUST POLICY. Being Open Policy

Transcription

1 TRUST POLICY Being Open Policy Author(s) Nicola Havutcu, Clinical Risk Manager (Interim) Diane Goodenough, Clinical Risk Manager Melanie Mavers, Head of Clinical Quality Version 2.0 Version Date February 2010 Minor revision July 2013 Implementation/approval Date August 2010 Review Date August 2013 Review Body Policy Reference Number Patient Safety Committee 176\tw\rm\bo\ Contents Version Control Summary Introduction Scope Roles and Responsibilities Policy Follow up Documentation Training and Awareness Monitoring and Review References Appendix 1: Being Open: encouraging open communication between healthcare organisations, healthcare teams, staff and patient/carer/relatives Appendix 2: Equalities Impact Assessment Appendix 3: Policy Submission Form... 18

2 Version Control Version Date Author Reason Ratification Required 1.0 Jan 2007 Samantha Eaton Jenny Negus Sadhna Chand Guy Young Lizzie Wallman To meet NPSA and NHSLA requirements Yes 1.1 Feb 2009 Nicola Havutcu, Interim Clinical Risk Manager David Bridger, Head of Governance Diane Goodenough, Clinical Risk Manager Melanie Mavers, Head of Clinical Quality 1.2 July 2013 Melanie Mavers, Head of Patient Safety Reviewed and updated to reflect current organisation structure, function and ensure compliance with NPSA and NHSLA requirements Revision to include duty of candour requirements Yes Yes 1. Summary The policy explains the process that must be followed by Trust staff in order to ensure open and honest communication with patients and their relatives following a patient safety incident, as a result of which, a patient has suffered moderate or severe harm or has died. The NPSA define a Patient Safety Incident as any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare (Seven Steps to Patient Safety, NPSA 2003). Moderate harm is defined by the NPSA as: Any patient safety incident that resulted in a moderate increase in treatment and that caused significant but not permanent harm. Moderate increase in treatment is defined as a return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another area such as intensive care as a result of the incident. Severe harm is defined by the NPSA as: Any patient safety incident that appears to have resulted in permanent harm. Permanent harm is defined as: Permanent harm directly related to the incident and not related to the natural course of the patient s illness or underlying condition is defined as permanent lessening of bodily functions, sensory, motor, physiological or intellectual, including removal of the wrong limb or organ, or brain damage. Death in this context is defined by the NPSA as: Any patient safety incident that directly resulted in the death. The death must be related to the incident rather than to the natural course of the patient s illness or underlying condition. If a serious incident has occurred but the patient did not suffer any harm, (e.g. medication error but the patient suffered no harm) a decision about whether to share this information with the patient/carer/relatives should be made on a case by case basis by the senior clinician in charge of the patient s care. There is no obligation to use the Being Open policy if the patient was not harmed. 2

3 2. Introduction The purpose of this policy is to outline the principles adopted by the Homerton University Hospital NHS Foundation Trust for ensuring that we are open and honest with patients and relatives when mistakes are made in the way we care for and treat patients. It is the duty of the consultant/senior clinician in charge of the patients care, to inform the patient when things go wrong regarding their care in line with the definitions in point 1. From April 2013 this good practice became part of the NHS contract and a requirement as the duty of candour (see appendix 2 for details). The National Patient Safety Agency (NPSA) advised all NHS organisations that they should implement a Being Open policy (revised Patient Safety Alert November 2009). Key actions for staff undertaking the Being Open process are: Open and honest communication An apology that the incident has occurred Support the patients and relatives Support the staff involved in Being Open discussions Document all Being Open discussions 3. Scope This policy applies to all employees of the Trust in all locations including Non Executive Directors, temporary employees, locums and contracted staff. 4. Roles and Responsibilities 4.1 Trust Board The Trust Board is responsible for actively championing the Being Open process by promoting an open and fair culture that fosters peer support and discourages the attribution of blame. The Board are also responsible for ensuring that changes identified from patient safety incidents are implemented and their effectiveness reviewed. 4.2 Chief Executive The Chief Executive is responsible for ensuring the infrastructure is in place to support openness between healthcare professionals and patient/carer/relatives following an incident that led to moderate harm, severe harm, or death. 4.3 The Chief Nurse and Director of Governance (Executive Lead for Being Open) Ensures that an appropriate support infrastructure is in place for staff involved in patient safety incidents, including staff that are responsible for leading Being Open discussions. 4.4 Non Executive Chair of the Risk Committee (Non-Executive Lead for Being Open) Ensures that the Being Open principles and policy are embedded in the organisation; through the Risk Committee. 4.5 The executive chairing the 24 hour meeting (24 hour meetings are held following potentially serious incidents see Incident reporting and SUI policy for further details) The chair of the 24 hour meeting will nominate the Being Open lead to support the patient/carer/relative. They will also nominate a senior clinical counsellor to support the Being Open lead (as necessary). 4.5 Clinical Directors/ Heads of Nursing / Midwifery As soon as it is practical following a patient safety incident where a patient was harmed it shall be the responsibility of the Clinical Director or Heads of Nursing / Midwifery (or Head of Service), to ensure that the most appropriate staff (Being Open Lead) are identified to meet with the patient/carer/relatives. 3

4 In most cases this may be the Consultant/Specialist Registrar and the Service Manager/Lead Nurse/Matron. Clinical Directors/Heads of Nursing/Midwifery will give consideration to the characteristics of the person nominated to lead the Being Open process, ensuring that the lead is senior enough and has sufficient experience and expertise in relation to the type of patient safety incident The Clinical Director/Heads of Nursing/Midwifery will ensure that there are adequate local support mechanisms in place for the staff involved in the patient safety incident and for the staff leading on the Being Open process. 4.6 Consultants/Heads of Nursing/Midwifery in the Role of Senior Clinical Counsellors The primary role of a Senior Clinical Counsellor (SCC) is to provide support to their colleagues in implementing the Being Open process. SCCs should support fellow healthcare professionals with the Being Open process by: mentoring colleagues during their first Being Open discussion; advising on the Being Open process; being accessible to colleagues prior to initial and subsequent Being Open discussions; facilitating the initial team meeting to discuss the incident when appropriate; sign posting the support services within the organisation for colleagues involved in Being Open discussions; facilitating debriefing meetings following Being Open discussions; mentoring colleagues to become Senior Clinical Counsellors. A SCC should only be asked to lead Being Open discussions when appropriate. 4.7 Being Open Leads The Being Open lead may be one of the following; A member of the Trusts executive team Consultant in charge of the patient s care Clinical Director Specialist registrar Head of Nursing/Midwifery Nurse / midwife Consultant Lead Nurse Matron The staff member nominated to be the Being Open Lead is responsible for ensuring the following: meeting with patient/carer/relatives involved in a patient safety incident; explaining what led to the incident occurring and any lessons learned; providing the patient/carer/relatives with a letter of apology; ensuring that the patient/carer/relatives has been provided with appropriate ongoing support; ensuring that the patient/carer/relatives has been provided with a contact name in the event of further queries or issues arising; arranging for transfer of care (to another medical team or Trust) where the patient requests this; documenting the details of all discussions with the patient/carer/relatives; Keeping in close communication with the incident investigation leads to enable regular and informed communication with the patient/carer/relatives. 4.8 Incident investigator (in cases where root cause analysis is being undertaken) 4

5 If the patient safety incident is being investigated in line with the Trusts Incident Reporting or Serious Incident (SI) Policy, the principle incident investigator must ensure that the Being Open lead is informed when the investigation process has been completed. 4.9 Patient Advice and Liaison Services (PALS) Staff If a patient/relative/carer brings an issue to the attention of the PALS team, which indicates that a patient has suffered harm as the result of a patient safety incident; the PALS team must report the incident using the Trust s Incident Reporting Policy All Healthcare Staff All staff working within the organisation will be expected to adhere to this policy. All staff have responsibility for ensuring that patient safety incidents are acknowledged and reported as soon as they are identified. Any patient safety incident resulting in harm that is graded as moderate or above, must be escalated to the relevant senior staff as soon as possible in line with the Trust s Incident Reporting Policy. 5. Policy 5.1 Process for acknowledging, apologising and explaining when things go wrong It is important to express regret that the patient has experienced a patient safety incident and suffered harm, within our Trust. Saying sorry is not an admission of liability, but an important part of acknowledging that harm has resulted from a patient safety incident. A patient has a right to openness in their healthcare. Meeting with the patient/relatives must take place within 10 working days of knowing the incident has taken place and caused harm to the patient. This should be a face to face meeting The patient/carer/relatives will also be informed that they may bring a friend to this meeting. Friends at these meetings are for support only and have no legal status. 5.2 The nominated Being Open Lead can continue to meet with the patient/carer/relatives to support continuity of communication and relationship building. 5.3 The meeting must be held within 10 days after the incident, taking into account the patient/carer/relatives home and social circumstances. 5.4 Information can be given at a formal meeting or in a more informal setting (consider the patients/carers/relatives requirements). 5.5 All communications related to Being Open about a patient safety incident with the patient/carer/relatives must be documented (whether the meeting is formal or informal) 5.6 The content of the initial Being Open discussion with the patient/carer/relatives should be conducted using appropriate terminology (avoiding medical jargon) and considering the language needs when English is not the patient/carer/relatives first language. The discussion should include the following: Express regret that this incident has happened at our Trust and apologise that it happened. If known, explain what went wrong and where possible, why it went wrong communicating through a chronology of clinical and other relevant facts. Give the patient/carer/relatives an opportunity to ask for an explanation as to why they thought it went wrong. Inform the patient/carer/relatives that a full investigation will be undertaken and, if known, what steps have been or will be taken to prevent the incident reoccurring. Check that the patient/carer/relatives has understood what has been explained to them. Provide opportunity for the patient/carer/relatives to ask any questions. 5

6 Arrange any future meetings if appropriate as well as providing information on what will happen next. Provide any information on short or long-term effects of the incident (if known) on the patient. Long term effects may have to be discussed at a subsequent meeting. Provide an offer of any practical and emotional support. Suggest any sources of support and counselling with written information. Provide a named contact in the Trust they can speak to following the meeting. It is essential that any information given is based on the facts known at the time and that the following does not occur during the Being Open discussion: Speculation Attribution of blame Denial of responsibility Provision of conflicting information from different individuals 5.7 Truthfulness, timeliness and clarity of communication Information about a patient safety incident must be given to patient/carer/relatives in a truthful and open manner by a Being Open lead (see above). Patients should be provided with a step-by-step explanation of what happened, that considers their individual needs and is delivered openly. Communication should also be timely; the patient/carer/relatives should be provided with information about what happened as soon as practicable. It should be explained that new information may emerge as an incident investigation is undertaken, and that the patient/carer/relatives will be kept up-to-date with the progress of an investigation. The patient/carer/relatives should be given a staff member as a single point of contact for any questions they may have (usually the Being Open lead). They should not receive conflicting information from different members of staff. The content of the initial Being Open discussion with the patient/carer/relatives should be conducted using appropriate terminology (avoiding medical jargon) and considering the language needs where English is not the patient/carer/relatives first language. 5.8 Process for encouraging open communication between healthcare organisations, healthcare teams, staff, and patient/carer/relatives In order to encourage open communication around patient safety incidents, the Being Open lead should ensure that the following are addressed in the course of the Being Open process (some of these points will be addressed after the initial meeting); Provide information to patient/carer/relatives in verbal and/or written format according to their needs/requirements. Provide assurance that the patient will continue to be treated according to their clinical needs and that the prospect of, or an actual dispute between, the patient/carer/relatives and the healthcare team will not affect their access to treatment. Facilitate inclusion of the patient s family and carers in discussions about a patient safety incident where the patient agrees. Provide the patient s family and carers with access to information to assist in making decisions if the patient is unable to participate in decision making or if the patient has died as a result of an incident. This should be done with regard to confidentiality and in accordance with the patient s instructions. Determine whether there is a need to repeat this information to the patient/carer/relatives at different times to allow them to comprehend the situation fully. Ensure that discussions with the patient/carer/relatives are documented and that information is shared with them. 6

7 Ensure that the patient/carer/relatives are provided with information on; The complaints procedure if they wish to have it. The incident reporting process. Ensure that the patient s account of the events leading up to the patient safety incident is fed into the incident investigation, whenever applicable. Once the investigation report has been ratified within the Trust: Ensure that the patient/carer/relatives are provided with a copy of any RCA investigation and are given the opportunity to discuss the findings. The copy of the report must be sent witin 10 days of ratification within the trust Consider very carefully how the RCA report should be shared with the patient/carer/relatives; as part of a meeting to discuss it or mailed to them in advance of a meeting to discuss it. No RCA report is to be released to patient/carer/relatives until it has been formally approved by the Trusts Patient Safety Committee. Ensure that the patient/carer/relatives are provided with information on how improvement plans derived from investigations will be implemented and their effects monitored. Wherever possible, send a brief communication to the patient s GP prior to discharge describing what has happened (with consent of the patient). It may be valuable to include the GP in one of the follow-up discussions either at discharge or at a later stage. If the patient has died, all the elements above apply in addition to: Ensure that the patient s family and carers are provided with known information, care and support if a patient has died as a result of a patient safety incident. The family and carers should also be referred to the coroner for more detailed information. 5.9 Advocacy and support Patient/carer/relatives may need considerable practical and emotional help and support after experiencing a patient safety incident. The most appropriate type of support may vary among different patient/carer/relatives. It is important to discuss with the patient/carer/relatives their individual needs. Support may be provided by patient s families, social workers, religious representatives and healthcare organisations such as PALS, Independent Complaints Advocacy Service (ICAS) and the Ombudsman. Where the patient/carer/relatives need more detailed long-term emotional support, advice should be provided on how to gain access to appropriate counselling and support services, for example, from Cruse Bereavement Care. The Being Open lead should ensure early identification of, and consent to assist with, the patient/carer/relatives practical and emotional needs. This includes: the names of people who can provide assistance and support to the patient, and to whom the patient has agreed that information about their healthcare can be given. This person (or people) may be different to both the patient s next of kin and from people who the patient had previously agreed should receive information about their care prior to the patient safety incident; any special restrictions on openness that the patient would like the healthcare team to respect; identifying whether the patient does not wish to know every aspect of what went wrong; respect their wishes and reassure them that this information will be made available if they change their mind later on. The Being Open Lead should also provide: Information on services offered by suitable support agencies (including their contact details) that can give emotional support, help the patient identify the issues of concern, 7

8 support them at meetings with staff and provide information about appropriate community services. Contact details of a staff member who will maintain an ongoing relationship for as long as necessary with the patient, using the most appropriate method of communication from the patient s, their family s and carers perspective. Their role is to provide both practical and emotional support in a timely manner. Information on the Being Open process. 6. Follow up Follow-up discussions (including formal feedback from a Trust investigation) with the patient/carer/relatives are an important step in the Being Open process. Depending on the incident, there may be more than one follow-up discussion. For all Being Open meetings the points raised in sections 5.6, 5.7 and 5.8 above should be followed in order to maintain consistency and continuity of approach. 7. Documentation Throughout the Being Open process it is important to document all Being Open discussions with the patient/carer/relatives. What should be documented? Relevant medical information relating to the patient in response to the patient safety incident in question. Documentation of all Being Open discussions/meetings with the patient/carer/relatives. The process for encouraging open communication between healthcare organisations, healthcare teams, staff, patient/carer/relatives. Where should it be documented? Patient s medical notes Patient s medical notes and/or separate document e.g. minutes of a formal meeting Use the document in this policy; Appendix 1 Responsible person Clinical staff caring for the patient. Being Open Lead Being Open lead (prompt from Quality and Risk Team) Where to be stored for evidence? Patient s medical notes Being Open Lead to send a copy of documentation to the Quality and Risk Department for filing Being Open Lead to send a copy to the Quality and Risk Department for filing Any correspondence sent to patient/carer/relatives or the GP. 24hr meeting minutes for potential Serious Investigations and Serious Untoward Incidents The actual letters sent to patient/carer/relatives or the GP. Risk Management team Being Open Lead Being Open Lead to send a copy to the Quality and Risk Department for filing If the incident has been the subject of a root cause analysis information will be in the report on the support given to the patient/carer/relatives. RCA report Incident investigator Quality and Risk Department to file on Datix 8

9 8. Training and Awareness This document will be made available on the Trust intranet site and publicised at the time of release. On line training via the NPSA NRLS website (see below for link) must be undertaken by all staff in the Senior Clinical Counsellor role. All other healthcare staff involved in communicating to patient/carer/relatives as part of the Being Open Policy are recommended to undertake this training. 9. Monitoring and Review This policy will be reviewed every three years or earlier in light of new national guidance or other significant change in circumstances. This policy will be monitored for effectiveness by the following processes: Measurable Policy Objective Demonstrate the implementation of the Being Open policy for all incidents graded moderate/severe/ death. Monitoring/Audit/ Assurance Audit of all incidents graded moderate/severe/ death to ensure that the Being Open policy has been applied and there is relevant documentation to support. Frequency of monitoring Annually Responsibility for performing the monitoring Clinical Risk Manager Monitoring reported to which groups/committees, inc responsibility for reviewing action plans Patient Safety Committee Demonstrate the process for encouraging open communication between healthcare organisations, healthcare teams, staff, patient/carer/relat ives Completed Appendix 1 forms Annually Clinical Risk Manager Patient Safety Committee Ensure staff in Senior Clinical Counsellor role have on line training Audit uptake of on line training by Staff in Senior Clinical Counsellor role. Annually Clinical Risk manager Patient Safety Committee 9

10 10. References NPSA Patient Safety Alert: NPSA/2009/PSA003. Being Open: communicating patient safety incidents with patients, their families and carers NPSA Patient Safety Alert: NPSA/2009/PSA003. Being Open Supporting Information National Patient Safety Agency (NPSA). Being Open Framework: Saying sorry when things go wrong

11 Appendix 1: Being Open: encouraging open communication between healthcare organisations, healthcare teams, staff and patient/carer/relatives. Being Open/Duty of Candour Name of Patient: Incident ID: Date of incident: Name of Senior Manager responsible for Being Open with this patient/family: Job Title of Senior Manager responsible for Being Open with this patient/family: Signature Senior Manager responsible for Being Open with this patient/family: Correct contact details for the patient carer/relatives: Phone Number (home and mobile) Postal address address: Have the following been carried out? Yes No N/A Comments/Details Date Stage 1 1 Has there been a face to face meeting with the patient/carer/relatives to explain the patient safety incident? If there has been a discussion but it was not in person please detail the reasons Was the meeting/contact within 10 working days of the incident? Have the patient/carer/relatives been given an apology? Have we provided information to patient/carer/relatives in verbal and/or written format according to their needs/requirement? Have we provided assurance that the 11

12 Have the following been carried out? Yes No N/A Comments/Details Date patient will continue to be treated according to their clinical needs and that the prospect of, or an actual dispute between, the patient/carer/relatives and the healthcare team will not affect their access to treatment? Facilitated inclusion of the patient s family and carers in discussions about a patient safety incident where the patient has agreed? Provided the patient s family/carers access to information to assist making decisions if the patient is unable to participate in decision making or if the patient has died as a result of an incident? This should be done with regard to confidentiality and in accordance with the patient s instructions. Determined whether there is a need to repeat this information to the patient/carer/relatives at different times to allow them to fully comprehend the situation? Documented all discussions with the patient/carer/relatives and shared this information with them? Copies of meeting notes/letters must be attached to the incident record. Provided the patient/carer/relatives with information on: The complaints procedure if they wish to have it. The incident investigation process including how we will feedback our investigation findings to them. Gathered the patient s account of events leading up to the patient safety incident and included it in the incident investigation, whenever applicable? Sent a brief communication to the patient s GP prior to discharge describing what has happened (with consent of the patient)? Consider including the GP in one of the follow-up discussions either at discharge or at a later stage. Stage 2 following completion of investigation 13 Date report/investigation was approved in the Trust: 12

13 Have the following been carried out? Yes No N/A Comments/Details Date Person/Committee that approved the report: 14 Provided the patient/carer/relatives with a copy of any SI/RCA investigation and given them the opportunity to discuss the findings? Consider very carefully how the SI/RCA report should be shared; as part of a meeting to discuss it or mailed to them in advance of a meeting to discuss it. No RCA report is to be released to patient/carer/relatives until it has been formally approved by the Patient Safety Committee If the report is technical a letter must be sent to explain terminology Date report sent to patient/carer/relatives Provided the patient/carer/relatives with information on how improvement plans derived from investigations will be implemented and their effects monitored? 17 If the patient has died, all the elements above apply and: Provided the patient s family and carers with information, care and support if a patient has died as a result of a patient safety incident? The carers and family should also be referred to the coroner for more detailed information. Please send a copy of this form to the Quality and Risk Team 13

14 APPENDIX 2 Duty of Candour (DoC) 1. Duty of candour became an NHS contractual responsibility in April The good practice requirements of Being Open are part of the NHS contract, times scales for compliance and penalties for non compliance apply. 3. In the following circumstances this process must be followed: The duty of candour applies when a patient safety incident has resulted in moderate harm, severe harm or death of a patient (NPSA definitions see below in appendix). The cause of the harm MUST be the patient safety incident. All patient safety incidents must be reported on the Trust local reporting system the date the incident was reported is the date the clock starts ticking. The DoC does not apply to incidents where there has been no harm or minor harm, but these incidents should be reported to the patient if appropriate. If any information about a patient safety incident is shared with a patient/family the full details of what information they have been given and by whom MUST be documented in the patients records and on the incident report form. The incident will require investigation to establish the facts; investigation must be in line with Trust policy and national guidance on serious incident investigations. The requirement of the duty of candour is part of the 24 hour meeting agenda. Time scales and required action Initial action From the point the incident is reported: The patient and their family/carer must be informed that a suspected or actual patient safety incident has occurred at most within 10 working days of the incident being reported to local systems sooner where possible. Even if it is unclear whether a patient safety incident has occurred or what degree of harm has been caused this is no reason to avoid disclosure. The field for duty of candour on the incident form must be marked by the handler of the incident as applicable. The initial notification must be verbal (face to face where possible) unless the patient cannot be contacted in person or declines. Take into account anything that may affect communication with the patient (language barriers, communication difficulties, relevant disability). This verbal communication must be accompanied by the offer of a letter all communication with the patients must be documented and attached to the Datix incident form for audit purposes the Being Open checklist can be used for this. A sincere apology must be provided this is not an admission of liability. The patient/family must be given a step by step explanation of what happened, in plain English, based on the facts known at the time as soon as possible. This maybe an initial view of the incident pending an investigation if so this must be made clear. 14

15 Identify a person of appropriate seniority to be the patient/family s point of contact for any further information. Full documentation of all meetings with patients/family in relation to the incident must be documented; the Being Open checklist should be used, the detail of what was discussed must be documented on the checklist this checklist/any other documentation must be attached to the incident form. During the investigation The patients/family should be provided with regular updates on the progress of the investigation by the allocated person. Following completion of the SI/RCA investigation Once the full investigation has been completed; the patient/family must be provided with a copy of the actual report, the action plan and if necessary a plain English explanation of the contents of the report this must be done within 10 working days of the report being signed off by the Patient Safety Committee. Knowledge of incidents causing harm by another route If a patient safety incident resulting in moderate, severe harm or death is detected by another route; complaint, concern raised by commissioners etc these are also subject to the DoC. Action for the Trust to demonstrate compliance with the contract and the DoC: Follow the process above Maintain written records of all conversations Keep all documentation on the risk management database under the patient safety incident reference number. The Trust should inform the commissioners when they are communicating with a patient/family about an incident. This does not need to be on a case by case basis and can take the form of regular report of the number of incidents concerned as part of the 6 monthly contractual review process. The Trust must be able to provide the following : o Copies of the documentation and information given to the patients/family to demonstrate compliance. If a complaint is received by the Trust alleging a potential breach of the contract in relation to reporting a patient safety incident, the Trust should inform the commissioners that this complaint has been received (this should be part of the current complaints handling process). 15

16 Appendix 3: Equalities Impact Assessment This checklist should be completed for all new Corporate Policies and procedures to understand their potential impact on equalities and assure equality in service delivery and employment. Policy/Service Name: Author: Role: Directorate: Being Open Policy Nicola Havutcu Clinical Risk Manager (Interim) Risk Management Date 8 th April 2010 Equalities Impact Assessment Question 1. How does the attached policy/service fit into the trusts overall aims? Yes No Comment Yes 2. How will the policy/service be implemented? 3. What outcomes are intended by implementing the policy/delivering the service? 4. How will the above outcomes be measured? Via the Risk Management Department as part of operational incident reporting policy and procedures All patients who sustain a moderate injury through a clinical incident are informed See Section 12 of policy 5. Who are they key stakeholders in respect of this policy/service and how have they been involved? 6. Does this policy/service impact on other policies or services and is that impact understood? 7. Does this policy/service impact on other agencies and is that impact understood? No Patient Safety Committee Incident Reporting Policy / linked referenced and understood 8. Is there any data on the policy or service that will help inform the EqIA? No 9. Are there are information gaps, and how will they be addressed/what additional information is required? No Equalities Impact Assessment Question Yes No Comment 16

17 10. Does the policy or service development have an adverse impact on any particular group? 11. Could the way the policy is carried out have an adverse impact on equality of opportunity or good relations between different groups? No No 12. Where an adverse impact has been identified can changes be made to minimise it? No 13. Is the policy directly or indirectly discriminatory, and can the latter be justified? No 14. Is the policy intended to increase equality of opportunity by permitting Positive Action or Reasonable Adjustment? If so is this lawful? No EQUALITIES IMPACT ASSESSMENT FOR POLICIES AND PROCEDURES 2. If any of the questions are answered yes, then the proposed policy is likely to be relevant to the Trust s responsibilities under the equalities duties. Please provide the ratifying committee with information on why yes answers were given and whether or not this is justifiable for clinical reasons. The author should consult with the Director of HR & Environment to develop a more detailed assessment of the Policy s impact and, where appropriate, design monitoring and reporting systems if there is any uncertainty. 3. A copy of the completed form should be submitted to the ratifying committee when submitting the document for ratification. The Committee will inform you if they perceive the Impact to be sufficient that a more detailed assessment is required. In this instance, the result of this impact assessment and any further work should be summarised in the body of the Policy and support will be given to ensure that the policy promotes equality. 17

18 Appendix 4: Policy Submission Form To be completed and attached to any policy or procedure submitted to the Trust Policy Group 1 Details of policy 1.1 Title of Policy: Being Open Policy 1.2 Lead Executive Director Charlie Sheldon, Chief Nurse and Director of Governance 1.3 Author/Title Nicola Havutcu, Clinical Risk Manager (Interim) Diane Goodenough, Clinical Risk Manager Melanie Mavers, Head of Clinical Quality 1.4 Lead Sub Committee Patient Safety Committee 1.5 Reason for Policy NPSA and NHSLA requirements 1.6 Who does policy affect? All clinical managerial staff 1.7 Are national guidelines/codes of practice incorporated? 1.8 Has an Equality Impact Assessment been carried out? 2 Information Collation 2.1 Where was Policy information obtained from? 3 Policy Management 3.1 Is there a requirement for a new or revised management structure if the policy is implemented? Yes NPSA requirements Yes NPSA Being Open Framework November 2009 NHSLA standard 5.10 requirements No 3.2 If YES attach a copy to this form 3.3 If NO explain why Existing Risk Management and Incident Reporting Processes being utilised 4 Consultation Process 4.1 Was there internal/external consultation? Internal 4.2 List groups/persons involved Patient Safety Committee Senior Nurses 4.3 Have internal/external comments been duly considered? Yes 4.4 Date approved by relevant Subcommittee 4.5 Signature of Sub committee chair 1 st April Implementation 18

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