BEING OPEN POLICY (incorporating Duty of Candour)

Transcription

1 BEING OPEN POLIC (incorporating Duty of Candour) To be read in conjunction with the Being Open Procedure and Guidance Document Author Written By: Clinical Risk & Claims Manager supported by Patient Experience Lead Authorised Signature Authorised By: Chief Executive Date: February 2015 Date: 23 rd March 2015 Lead Director: Executive Director of Nursing Effective Date: 23 rd March 2015 Review Date: 22 nd March 2017 Approval at: Trust Executive Committee Date Approved: 23 rd March 2015 Being Open Policy Page 1 of 23

2 DOCUMENT HISTOR (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Date Approved Director Responsible for Change 29 Mar Carol Alstrom / Dr Mark Pugh Nature of Change Logo and wording updated for new organisation Ratification / Approval 14 Nov Dr Mark Pugh Put into new template 6 Dec Dr Mark Pugh Ratified at Quality & Patient Safety Committee 14 Dec Dr Mark Pugh Ratified at Policy Management Group 17 Dec Dec 12 Dr Mark Pugh Approved at Executive Board 16 Dec Dec 14 Executive Director of Nursing 28 Feb Executive Director of Nursing 6 Mar Executive Director of Nursing 17 Mar Executive Director of Nursing 23 Mar 15 6 Executive Director of Nursing 3 Month Extension Reviewed Approved at Policy Management Group Clinical Standards Group Ratified at Clinical Standards Group Ratified at Policy Management Group Approved at Trust Executive Committee NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust. Being Open Policy Page 2 of 23

3 Contents Page 1. Executive Summary 4 2. Introduction 5 3. Scope 6 4. Purpose 6 5. Roles and Responsibilities 7 6. Policy detail / course of action 8 7. Consultation Training Dissemination Process Equality Analysis Review and Revision arrangements Monitoring Compliance and Effectiveness Links to Other Organisation Policies/Documents References Disclaimer 12 Appendices: A. Key Definitions 13 B. Checklist for the development and approval of controlled 14 Documentation C. Impact assessment forms on policy implementation 17 (including checklist) D. Equality analysis and action plan 21 Being Open Policy Page 3 of 23

4 1. EXECUTIVE SUMMAR Every day more than a million people are treated safely in the NHS. But, occasionally something goes wrong and a patient is harmed. Healthcare staff may feel cautious about apologising for things that go wrong as they worry that they might say the wrong things, make the situation worse and may automatically be blamed for the mistake. However, patients and their families can cope better if healthcare staff are open about mistakes. Being Open means that someone involved in the treatment should talk to patients, relatives and carers to explain what went wrong. The effects of harming a patient can be widespread. Patient safety incidents can have devastating emotional and physical consequences for patients, their families and carers, and can be distressing for the professionals involved. Being Open about what happened and discussing patient safety incidents promptly, fully and compassionately can help patients and professionals to cope better with the after-effects. Openness and honesty can also help to prevent such events becoming formal complaints and litigation claims. 1.1 What does Being Open mean? Being open involves: acknowledging, apologising and explaining when things go wrong; conducting a thorough investigation into the incident and reassuring patients, their families and carers that lessons learned will help prevent the incident recurring; providing support for those involved to cope with the physical and psychological consequences of what happened. It is important to remember that saying sorry is not an admission of liability and is the right thing to do. 1.2 The principles The set of principles has been developed to help healthcare organisations create and embed a culture of Being Open and these are outlined in the supporting procedure document entitled Being Open Procedure and Guidance. 1.3 Implementing Being Open Previously the National Patient Safety Agency (NPSA) developed an updated framework to demonstrate how to strengthen the culture of Being Open within healthcare organisations. The framework provides best practice guidance on how to create an open and honest environment Commitment to Being Open helps to create an environment where patients, their families and carers receive the information they need to understand what happened, and the reassurance that everything possible will be done to ensure that a similar type of incident does not recur. Patients, their families and carers, healthcare professionals and managers should all feel supported when things go wrong. 1.4 What is Duty of Candour legislation? The Duty of Candour regulation is in place to ensure Trusts are open and transparent with the relevant person when certain incidents occur in relation to the care and treatment provided to people who use services in the carrying on a regulated activity. The introduction of the regulation in a direct response to Recommendations 181 of the Frances Enquiry report into Mid Staffordshire NHS Foundation Trust, which recommended that a statutory duty of candour for patients injury be imposed on healthcare providers. Being Open Policy Page 4 of 23

5 2. INTRODUCTION 2.1 The National Reporting and Learning Service (NRLS) have updated the Being Open framework and a further Patient Safety Alert (NPSA/2009/PSA003) has been produced setting out actions to be undertaken by the NHS. This policy and the supporting procedure outline the requirements within the Isle of Wight NHS Trust. 2.2 Regulation 20: Duty of Candour has been introduced by the CQC which makes it a statutory duty for NHS Trusts to ensure that we act in an open and transparent way when a notifiable safety incident has occurred and providing support to them throughout the process. 2.3 Openness and communicating effectively with patients, their families and carers is a vital part of the process of dealing with patient safety incidents in healthcare. Research has shown that patients are more likely to forgive medical errors when they are discussed in a timely and thoughtful manner and that being open can decrease the trauma felt by patients following a patient safety incident. 2.4 Openness also has benefits for healthcare professionals as it can; help to reduce stress through the use of a formalised, honest communication method; alleviate the fear of being found out and improve job satisfaction by: Ensuring that communication with patients, their families and carers has been handled in the most appropriate way; Helping the healthcare professional to develop a good professional reputation for handling a difficult situation property; and Improving the healthcare professional s understanding of incidents from the perspective of the patient, their family and carers. 2.5 The benefits of Being Open are widely recognised and supported by policy makers, professional bodies, and litigation and indemnity bodies, including the Department of Health, General Medical Council (GMC), National Health Service Litigation Authority (NHSLA), Medical Defence Union (MDU) and the Medical Protection Society (MPS). The NHS Constitution for England embeds the principles of Being Open as a pledge to patients in relation to complaints and redress. It states: The NHS also commits when mistakes happen to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. The Constitution recommends that staff should view the services they provide from the standpoint of patient and involve patients, their families and carers in the services they provide, working with them, their communities and other organisations. The GMC in their handbook Good Medical Practice, also advise that: If a patient under your care has suffered serious harm, through misadventure, or for any other reason, you should act immediately to put matters right, if that is possible. ou should explain fully to the patient what has happened and the likely long and short-term effects. When appropriate, you should offer an apology. More detail of the benefits to healthcare organisations, professionals and patients are outlined in the supporting procedure. Being Open Policy Page 5 of 23

6 2.6 If the patient is under 16 and lacks the maturity to consent to treatment, you should explain the situation honestly to those with parental responsibility for the child. 2.7 Promoting a culture of openness is a prerequisite to improving patient safety and the quality of healthcare systems. Being Open involves: Acknowledging, apologising and explaining when things go wrong; Conducting a thorough investigation into the incident and reassuring patients, their families and carers that lessons learned will help prevent the incident recurring; and Providing support for those involved to cope with the physical and psychological consequences of what happened. It is important to remember that saying sorry is not an admission of liability and is the right thing to do. 2.8 To implement Being Open successfully, healthcare organisations need to have the following foundations A culture that is open and fair A local Being Open policy and mechanisms to raise awareness about it Staff and patient support for Being Open. A culture of openness ensures communication is open, honest and occurs as soon as possible following an incident, or when a poor outcome has been experienced. It encompasses the communication between healthcare organisations, healthcare teams and patients, their families, and carers, and ensures that healthcare organisations support their staff in Being Open. 2.9 This policy is integrated with local and national incident reporting, risk management and concerns and complaints policies. The following legal and regulatory requirements must also be taken into account: Good Complaint Handling principles are consistent with Being Open;; National Health Service Litigation Authority Circular May 2009; and Regulation 20: Duty of Candour Care Quality Commission November SCOPE This policy applies to all healthcare staff employed by the Trust. Independent contractors providing services for NHS Isle of Wight are also encouraged to adopt this policy or to develop similar procedures also based on the National Reporting and Learning System (NRLS) guidance. 4. PURPOSE The purpose of this policy and process sets out the procedure for encouraging open communication between all parties when things go wrong. It establishes the requirements for acknowledging and apologising, including the clarity of communication and documentation. It also ensures that we are complying with Regulation 20: Duty of Candour, and our contractual requirements under Condition 35 of the contract Being Open Policy Page 6 of 23

7 5. ROLES AND RESPONSIBILITIES There is a commitment required throughout the organisation in respect of adherence to the principles of this policy, and the Board and Senior Managers across the Trust have a crucial role to play in ensuring the Being Open framework and process are embedded as a core of the organisation s values and a culture of working with patients, the public and staff. 5.1 The Trust Board The Board is responsible for ensuring that a Being Open policy is in place and is fully implemented throughout the organisation that supports Regulation 20. The Board has nominated the Executive Director of Nursing and an Executive Medical Director who will be responsible for leading the local policy, and identify senior clinical councillors to support and mentor fellow clinicians. The Board should gain assurance that the proposed strategy for training and awareness is put in place to raise awareness amongst all staff of the Being Open framework. This should include providing all staff engaged in patient care with sufficient skills and knowledge to allow them to practice the Being Open principles and feel confident in communicating with patients, their families and carers when things go wrong. This also extends to ensuring that Senior Clinical Counsellors are fully equipped with the knowledge and skills that they require in order to fulfil their role on supporting staff. 5.2 The Chief Executive To demonstrate the Board s commitment, the Chief Executive endorses the principles of Being Open, setting out the duty of all staff to follow the Being Open principles and reinforcing the organisation s full support of an open, honest and fair culture. This commitment will be reinforced at a public meeting of the Board following the approval of the policy. When a major incident occurs or where a criminal act is suspected, the Chief Executive or if out of hours the Executive On Call, must be notified immediately as per the reporting system detailed in the Incident Reporting and Management Policy 5.3 The Executive Director of Nursing and Executive Medical Director These nominated individuals are responsible for leading on the development and implementation of this policy and its supporting procedure. 5.4 Senior Managers/Line Managers It is the responsibility of all Senior Managers/Line Managers to guide the member of staff reporting the incident on how to proceed with the Being Open process and where necessary to offer appropriate support to this individual and to ensure that we clearly meet the requirements under Regulation Senior Clinical Counsellors These individuals, to include the Associate Director of Medical Education, the Clinical Directors and the Medical Director, will be responsible for mentoring and supporting other colleagues. They should give advice on the process, facilitate debriefing sessions, Being Open Policy Page 7 of 23

8 signpost support staff, advise on the reporting system for patient safety incidents and generally promote the principles of Being Open. 5.6 Head of Corporate Governance & Risk Management, Clinical Risk & Claims Manager, Assistant Director Health, Safety and Security These individuals are responsible for notifying relevant agencies such as the Isle of Wight Clinical Commissioning Group (CCG), Trust Development Agency, NRLS or Health & Safety Executive about the incident and any further issues. 5.7 Patient Experience Officers (PEOs) These officers will help to support patients through the process acting as advocates if requested by the relevant person. 5.8 The person reporting the incident This person should firstly ensure that the patient is safe and not placed at any further risk. Once this has been achieved they should inform their immediate line manager, Consultant and the Risk Management Department either by telephone, electronically and by completion of the incident form. The NRLS will then receive anonymous notification of the incident through the National Reporting and Learning System. 5.9 All staff All staff are responsible for being familiar with this policy, reporting patient safety incidents and Being Open with patients. Failure to do so may result in action being taken in accordance with Disciplinary and Dismissal Policy, and / or Conduct, Capability, Ill Health and Appeals Policy and Procedure for Medical and Dental Practitioners For Bank staff this will be managed in line with Bank Workers Code of Conduct. 6. POLIC DETAIL/COURSE OF ACTION The flow chart below outlines the core elements of the Being Open policy and the process that staff should follow to ensure that being open is managed effectively whatever the setting. The details of each step are outlined in the supporting Being Open Procedure and Guidance document. Being Open Policy Page 8 of 23

9 Incident detected or recognised our First Action Must be to ensure the patient is safe provide prompt and appropriate clinical care to prevent further harm Report incident in line with incident reporting policy and advise the responsible senior clinician Preliminary Team Discussion to Undertake initial assessment when it is clear how the harm occurred ensure that the staff member/s involved are made aware and appropriately supported Establish the timeline Identify who will lead communication Initial Being Open discussion with patient/relatives/carers should be done by senior healthcare professional Verbal and written apology Provide known facts to date Offer practical and emotional support Identify next steps for keeping them informed Follow-up Discussion Provide update on known facts at regular/agreed intervals Process completion Discuss the findings of the investigation and analysis with the patient / relative / carer Inform on plans for ongoing care Share summary of investigation/analysis with relevant people Monitor the implementation of the action plan Communicate the learning from the incident with staff Add to Incident Form on Datix Being Open Policy Page 9 of 23

10 7. CONSULTATION This document will be disseminated through e-bulletin prior to going through the formal ratification route. 8. TRAINING This Being Open Policy and Procedure does not have a mandatory training requirement but the following non mandatory training is recommended: A Being Open e-learning module is available for all front line staff through the NHS s National Learning System (NLMS). Although this is a separate e-learning platform to the Trust s already established Training Tracker system, usernames and passwords can be provided to all staff from the Education, Training and Development department by sending an ed request to Pro4updates@iow.nhs.uk A specific training course for all individuals with key responsibilities within the policy will also be provided. This should be completed every 3 years. Evidence of this training will be registered on the Training Manager Pro4 System. Elements of Being Open and the Being Open policy are included in the Trust s local training programme for Serious Incidents Requiring Investigation (SIRI) and Root Cause Analysis. The Clinical Risk & Claims Manager, along with risk management colleagues in Southampton, Portsmouth and Winchester have completed the NRLS training course on Being Open and are therefore able to deliver training on Being Open. 8.1 Supporting information and tools In addition to this framework, supporting tools have been developed to assist healthcare organisations with implementing the actions of the NPSA s Being Open Patient Safety Alert. Training on Being Open is freely available through an e-learning tool. Interactive training workshops that use actors and/or video-based materials can also be commissioned by organisations. Information on all these supporting tools can be found at: 9. DISSEMINATION 9.1 When approved this document will be available on the Intranet and will be subject to document control procedures. Approved documents will be placed on the Intranet within 5 working days of date of approval once received by the Risk Management Team. 9.2 When submitted to the Risk Management Team for inclusion on the Intranet this document will have fully completed document details including version control. Keywords and description for the Intranet search engine will be supplied by the author at the time of submission. 9.3 Notification of new and revised documentation will be issued on the Front page of the Intranet, through e-bulletin, and on staff notice boards where appropriate. Any controlled documents noted at the Policy Management Group / Trust Executive Committee will be notified through the e-bulletin. Being Open Policy Page 10 of 23

11 9.4 Staff using the Trust s intranet can access all procedural documents. It is the responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work. 9.5 It is the responsibility of each individual who prints a hard copy of any document to ensure that the printed hardcopy is the current version. Current versions are maintained on the Intranet. 10. EQUALIT ANALSIS This procedure has undergone an equality analysis please refer to Appendix A 11. REVIEW AND REVISION ARRANGEMENTS This policy will be reviewed on a regular basis, not less than 2 yearly. Responsibility of this lies with the author of this document. 12. MONITORING COMPLIANCE AND EFFECTIVENESS The results of Being Open discussions with patients and/or careers will be fed back to the Manager leading the incident investigation process. This will be recorded on Datix. A review of all Serious Incidents Requiring Investigation will be undertaken on an annual basis to see how many of these have involved the Being Open/Duty of Candour process. Those that involve patient care will be reviewed to ensure that the requirement of the process have been understood and adhered to. Results of this will be reported to the Quality & Clinical Performance Committee on a yearly basis by the Patient Experience Lead and or the Clinical Risk & Claims Manager. 13. LINKS TO OTHER TRUST POLICIES/DOCUMENTS This policy should be read in conjunction with: * Incident Reporting and Management Policy (to be read in conjunction with SIRI Procedure) * Seven steps to patient safety - National Patient Safety Agency 2004 * National Patient Safety Agency - Being Open, communicating patient safety incidents with patients and their carers 2009 * Safer Practice Alert NPSA/2009/PSA003 - Being Open - National Patient Safety Agency 19 November 2009 * Policy for consent to examination and treatment Isle of Wight NHS Trust November 2014 * Complaints & Compliments Policy - Isle of Wight NHS Trust December * National Framework for Reporting and Learning from Serious Incidents requiring Investigation National Reporting and Learning System March 2010 * Conduct, Capability, Ill Health and Appeals Policy and Procedure for Medical and Dental Practitioners 2011 * Disciplinary and Dismissal Policy 2017 * Code of Conduct for Bank Workers. Being Open Policy Page 11 of 23

12 14. REFERENCES Crane M, What to say if you make a mistake, Medical Economics 2001 National Patients Safety Agency, Seven Steps to Patient Safety, Involve and communicate with patients and the public, Available at National Health Service Litigation Authority (NHSLA) circular 02/02 Apologies and Explanations, February Available at Department of Health Chief Medical Officer s consultation document, Making Amends, The Stationery Office Available at General Medical Council, Good Medical Practice, Available at Department of Health Harold Shipman s clinical practice ; a clinical audit commissioned by the Chief Medical Officer (5th Shipman Inquiry Report) Crown Copyright X Kaplin C and Hepworth S, Supporting health service staff involved in a complaint, incident or claim, an NHS Litigation Authority s initiative. NHSLA journal 2004 issue DISCLAIMER It is the responsibility of all staff to check the Trust intranet to ensure that the most recent version/issue of this document is being referenced. Being Open Policy Page 12 of 23

13 Appendix A KE DEFINITIONS FOR DOCUMENTATION CQC GMC MDU MPS NHSLA NPSA NRLS SIRI Care Quality Commissioning General Medical Council Medical Defence Union Medical Protection Society National Health Service Litigation Authority National Patient Safety Alert National Reporting and Learning System Serious Incident Requiring Investigation Being Open Policy Page 13 of 23

14 Appendix B CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENTATION To be completed and attached to any document when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: 1. Title/Cover Is the title clear and unambiguous? Does the title make it clear whether the controlled document is a guideline, policy, protocol or standard? 2. Document Details and History Have all sections of the document detail/history been completed? 3. Development Process 4. Is the development method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Review and Revision Arrangements Including Version Control Is the review date identified? Is the frequency of review identified? If so, is it acceptable? Are details of how the review will take place identified? Does the document identify where it will be held and how version control will be addressed? 5. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? 6. Consultation Do you have evidence of who has been consulted? 7. Table of Contents Has the table of contents been completed and checked? /N/ Unsure N N/A Comments Information not readily available Being Open Policy Page 14 of 23

15 Title of document being reviewed: 8. Summary Points Have the summary points of the document been included? 9. Definition Is it clear whether the controlled document is a guideline, policy, protocol or standard? 10. Relevance Has the audience been identified and clearly stated? 11. Purpose Are the reasons for the development of the document stated? 12. Roles and Responsibilities Are the roles and responsibilities clearly identified? 13. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 14. Training Have training needs been identified and documented? 15. Dissemination and Implementation 16. Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? Process to Monitor Compliance and Effectiveness Are there measurable standards or Key Performance Indicators (KPIs) to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance within the document? Is it clear who will see the results of the audit and where the action plan will be monitored? 17. Associated Documents Have all associated documents to the document been listed? 18. References Have all references that support the document been listed in full? /N/ Unsure Comments Being Open Policy Page 15 of 23

16 Title of document being reviewed: 19. Glossary Has the need for a glossary been identified and included within the document? 20. Equality Analysis Has an Equality Analysis been completed and included with the document? 21. Archiving Have archiving arrangements for superseded documents been addressed? Has the process for retrieving archived versions of the document been identified and included within? 22. Format and Style Does the document follow the correct style and format of the Document Control Procedure? 23. Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? Committee Approval /N/ Unsure N N Comments If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee Print Name Date Signature of Chair Being Open Policy Page 16 of 23

17 Appendix C IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION Summary of Impact Assessment (see next page for details) Document title Being Open Policy Totals WTE Recurring Non Recurring Manpower Costs Nil Nil Nil Training Staff Nil Nil In house Nil In house Equipment & Provision of resources Nil Nil Nil Summary of Impact: This policy underpins and formalises communication with patients/carers which is generally happening throughout the organisation already. As part of the extended framework the Trust s Executive Director of Nursing and Workforce and Medical Director, along with a Non-Executive, will lead the local policy and identify senior clinical counsellors to support fellow clinicians. There will therefore be no additional manpower costs incurred as a result of this policy and staff will undertake the requirements of the policy during their normal working hours. No additional staff will be required to implement the policy. The Clinical Risk & Claims Manager has undertaken the National Patient Safety Agency training program to deliver the necessary training required under the policy. There is also an agreement in the South East region that cross-cover and joint training will also be provided by Risk Manager colleagues from across the region. No additional equipment or resources will be required. Risk Management Issues: There is a national requirement from the NRLA that each organisation has a local Being Open policy. Benefits / Savings to the organisation: The main benefits and savings to the Trust will be to continue to develop good communication and openness with patients/carers when things do not go as planned. It is well recognised that being open leads to a reduction on the number of complaints and litigation claims. Being Open Policy Page 17 of 23

18 Equality Impact Assessment Has this been appropriately carried out? ES Are there any reported equality issues? NO If ES please specify: Use additional sheets if necessary. Being Open Policy Page 18 of 23

19 IMPACT ASSESSMENT ON POLIC IMPLEMENTATION Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Nil Nil Nil Operational running costs Additional staffing required - by affected areas / departments: Nil Nil Nil Totals: Nil Nil Nil Staff Training Impact Recurring Non-Recurring Affected areas / departments Nil Nil e.g. 10 staff for 2 days Totals: Nil Nil Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed Building alterations (extensions/new) Nil Nil IT Hardware / software / licences Nil Nil Medical equipment Nil Nil Stationery / publicity Nil Nil Travel costs Nil Nil Utilities e.g. telephones Nil Nil Process change Nil Nil Rolling replacement of equipment Nil Nil Equipment maintenance Nil Nil Marketing booklets/posters/handouts, etc Nil Nil Totals: Nil Nil Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Being Open Policy Page 19 of 23

20 IMPACT ASSESSMENT ON DOCUMMENT IMPLEMENTATION - CHECKLIST Points to consider Have you considered the following areas / departments? Have you spoken to finance / accountant for costing? Where will the funding come from to implement the policy? Are all service areas included? o Ambulance o Acute o Mental Health o o Community Services, e.g. allied health professionals Public Health, Commissioning, Primary Care (general practice, dentistry, optometry), other partner services, e.g. Council, PBC Forum, etc. Departments / Facilities / Staffing Transport Estates o Building costs, Water, Telephones, Gas, Electricity, Lighting, Heating, Drainage, Building alterations e.g. disabled access, toilets etc Portering Health Records (clinical records) Caretakers Ward areas Pathology Pharmacy Infection Control Domestic Services Radiology A&E Risk Management Team / Information Officer responsible to ensure the policy meets the organisation approved format Human Resources IT Support Finance Rolling programme of equipment Health & safety/fire Training materials costs Impact upon capacity/activity/performance Being Open Policy Page 20 of 23

21 Appendix D Step 1. Identify who is responsible for the equality analysis Name: Claire Willis Equality Analysis and Action Plan Role: Clinical Risk & Claims Manager Other people or agencies who will be involved in undertaking the equality analysis: Vanessa Flower, Patient Experience Lead Step 2. Establishing relevance to equality Show how this document or service change meets the aims of the Equality Act 2010? Equality Act General Duty Eliminates unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and people who do not share it Foster good relations between people who share a protected characteristic and people who do not share it. Relevance Protected Groups Staff Service Users Wider Community Age Gender Reassignment Race Sex and Sexual Orientation Religion or belief Disability Marriage and Civil Partnerships Human Rights Pregnancy and Maternity Relevance to Equality Act General Duties All people affected will be treated the same Being Open Policy Page 21 of 23

22 Step 3. Scope your equality analysis What is the purpose of this document or service change? Who will benefits? What are the expected outcomes? Why do we need this document or do we need to change the service? Scope To acknowledge, apologise and explain to patients, careers and relatives when things go wrong There will be benefits for patients, carers, relatives, staff and Executive leads To establish a culture of openness within the Trust To ensues that we have a set process that everyone is aware of and can follow to ensure that all patients are treated in a similar way It is important that appropriate and relevant information is used about the different protected groups that will be affected by this document or service change. Information from your service users is in the majority of cases, the most valuable. Information sources are likely to vary depending on the nature of the document or service change. Listed below are some suggested sources of information that could be helpful: Results from the most recent service user or staff surveys. Regional or national surveys Analysis of complaints or enquiries Recommendations from an audit or inspection Local census data Information from protected groups or agencies. Information from engagement events. Step 4. Analyse your information As yourself two simple questions: What will happen, or not happen, if we do things this way? What would happen in relation to equality and good relations? In identifying whether a proposed document or service changes discriminates unlawfully, consider the scope of discrimination set out in the Equality Act 2010, as well as direct and indirect discrimination, harassment, victimization and failure to make a reasonable adjustment. Findings of your analysis No major change Adjust your document or service change proposals Description our analysis demonstrates that the proposal is robust and the evidence shows no potential for discrimination. This involves taking steps to remove barriers or to better advance equality outcomes. This might include introducing measures to mitigate the potential effect. Justification of your analysis This document ensures there will be no discrimination within the Being Open policy and procedure and guidance Being Open Policy Page 22 of 23

23 Continue to implement the document or service change Stop and review Despite any adverse effect or missed opportunity to advance equality, provided you can satisfy yourself it does not unlawfully discriminate. Adverse effects that cannot be justified or mitigated against, you should consider stopping the proposal. ou must stop and review if unlawful discrimination is identified 5. Next steps 5.1 Monitoring and Review. Equality analysis is an ongoing process that does not end once the document has been published or the service change has been implemented. This does not mean repeating the equality analysis, but using the experience gained through implementation to check the findings and to make any necessary adjustments. Consider: How will you measure the effectiveness of this By reviewing the Equality Act 2010 change When will the document or service change be Every 2 years reviewed? Who will be responsible for monitoring and Claire Willis review? What information will you need for monitoring? A review of the Equality Act 2010 How will you engage with stakeholders, staff By the ratification process and service users 5.2 Approval and publication The Policy Management Group / Trust Executive Committee will be responsible for ensuring that all documents submitted for approval will have completed an equality analysis. Under the specific duties of the Act, equality information published by the organisation should include evidence that equality analyses are being undertaken. These will be published on the organisations Equality, Diversity and Inclusion website. Useful links: Equality and Human Rights Commission Being Open Policy Page 23 of 23