Central Alert System (CAS) Policy

Transcription

1 Reference Number: Version: 2 Name of Originator / Author & Organisation: Responsible LECCG Committee: LECCG Executive Lead: Date Approved by LECCG Authorising Committee: CIG005 Tracy Wilburn, Federated Clinical Risk Management Team, Hosted by WLCCG Risk & Governance Committee Tracy Pilcher, Chief Nurse Review date: March 2017 Target audience: Distributed via: All Staff Website Intradoc Date Policy Circulated: Page 1 of 8

2 Version Control Sheet Version Number Changes: Whole Revision/ Section/ Paragraph/ Appendix Description of Amendments Date Ratified Author / Originator / Amended by 2.0 Whole Revision Complete re-write Dec 2014 Tracy Wilburn, Patient Safety Manager Federated Clinical Risk and Compliance Team, LWCCG Page 2 of 8

3 Contents 1. Roles and Responsibilities 4 2. Background 4 3. Implementation 5 4. Monitoring of Central Alert System Implementation by Main Care Providers 6 5. Review 6 Appendix 1 - Central Alert Action Plan 7 Appendix 2 - Central Alerting System (CAS) Distribution Return Slip 8 Page 3 of 8

4 1. Roles and Responsibilities The Clinical Commissioning Group has a responsibility to ensure that the services they commission are safe. To fulfil this responsibility the Clinical Commission Group will be responsible: For reviewing the Central Alert System (CAS) alerts notified and cascade alerts to appropriate individuals within the Clinical Commissioning Group; to support the safe commissioning of care in their respective speciality areas For cascading alerts to appropriate Any Qualified Professional (AQP) Services directly commissioned by the Clinical Commissioning Groups For providing positive challenge to Provider Organisations to ensure the appropriate implementation and closure of alerts on the Central Alert System (CAS) is undertaken The Accountable Officer within the Clinical Commissioning Group has the ultimate responsibility for the management and distribution of the Central Alerts System (CAS) alerts in accordance with this policy. The strategic responsibility for the CAS system is delegated through to the Clinical Commissioning Group Executive Lead Nurse, supported operationally by the federated Clinical Risk Management Team. The operational responsibility for the review and distribution of the CAS alerts, within the Clinical Commissioning Group is undertaken by the Patient Safety Manager of the federated Clinical Risk Management Team; supported by the Risk Administration Assistant. This policy relates to the responsibilities of the Lincolnshire Clinical Commissioning Groups. Primary recipients of CAS alerts are responsible for assessing their relevance to their operational area, acting to secure the implementation of relevant alerts and reporting compliance status to the Risk Administration Assistant within the stipulated timescale. 2. Background The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. The responsibility to cascade alerts to primary care contractors to action; and to monitor the implementation of alerts by contractors transferred to the NHS Commissioning Board Area Teams in April The Clinical Commissioning Group retained the responsibility to ensure that the services they commission are provided safely; responding appropriately to Central Alert System (CAS) alerts where appropriate. The federated Clinical Risk Management Team, on behalf of the Lincolnshire CCGs, monitor the CAS alerts issued; and ensure that these are managed and compliance monitored through the CAS process. Page 4 of 8

5 3. Implementation The process for managing alerts within the Clinical Commissioning Groups is divided into four distinct phases. The Central Alert System Policy has been divided into these phases for ease of reading. Phase 1 Receipt of Alert, Assessment of Applicability An automatic notification from the Central Alert System is received within the central secure federated Clinical Risk Management account on behalf of the Lincolnshire Clinical Commissioning Groups (lwccg.clinicalriskincidents@nhs.net). When the alert is received into the federated Clinical Risk Management Team, the Risk Administration Assistant will assess the alert for applicability; develop an initial action plan describing proposed dissemination which is then reviewed by the Patient Safety Manager or nominated deputy. Specialist advice may also be sought from colleagues, to support appropriate onward management of alerts relating to specialist areas of responsibility. The action plan developed will be recorded on an electronic template (appendix 1). Phase 2 Circulation of Alerts The Risk Administration Assistant or nominated deputy will disseminate the alert as follows: * circulation of the alert to primary recipients as indicated by the action plan, identifying whether the alert is for action or for information only *This may include circulation ( /paper-based) of the alert to appropriate Any Qualified Providers identifying whether the alert is for circulation or for information only. A number of alerts may be identified as not applicable to the role of the Clinical Commissioning Group. In these instances, a summary of the alert and the decision made not to distribute will be recorded in the action plan documentation for audit purposes. Phase 3 Implementation When action is indicated following receipt of an alert, an action plan will be produced by the primary recipients. The action plan will clearly identify proposed onward circulation and action and ensure compliance. Primary recipients are required to disseminate the alert to appropriate personnel within their team or service, documenting required action within a local plan. Primary recipients are required to keep an audit trail of action taken, linking with training leads and other expert resources as appropriate to ensure implementation. The primary recipients will be responsible for reporting implementation progress within the timescale stated on the alert. Risk identified in relation to non compliance with an alert will be escalated to the Executive Lead Nurse for management directly with the primary recipient. Phase 4 Reporting Primary recipients will report progress to the Risk Administration Assistant using the Central Alert System return slip (Appendix 2). Page 5 of 8

6 Where full implementation within the timescale is not possible this should be communicated promptly to the Risk Administration Assistant or Patient Safety Manager and considered for inclusion on the Clinical Commissioning Group Risk Register. 4. Monitoring of Central Alert System Implementation by Main Care Providers Acute, Mental Health, Community Organisations; Nursing Homes and Independent Hospitals are required to register, receive and implement alerts from the Central Alerting System (CAS). The Clinical Commission Group in their role as lead commissioners monitor the implementation of CAS alerts by the main healthcare organisations, from which NHS services are commissioned The implementation of CAS alerts is a standard agenda item on the quarterly Patient Safety Meetings and Contract Quality Review Meetings for the appropriate providers. Further assurance is sought directly with care providers in relation to the implementation of action plans for multi-agency alerts; and where specific concerns have been identified in relation to an alert disseminated through the Central Alert System (CAS). 5 Review This policy will be reviewed on an annual basis by the federated Clinical Risk Management Team. Page 6 of 8

7 Appendix 1 Central Alert Action Plan DATE DISTRIBUTED INTERNALLY TO T WILBURN DEADLINE DATE (ACTION UNDERWAY) DEADLINE DATE (ACTION ACTION/ COMMENTS Alert circulated to (by Risk Team) CLOSED COMPLETE) 28/04/ /04/2014: Reviewed by T Wilburn:Many thanks - would suggest sending to CCG managed CHC colleagues / resposible for the placement of mental health patient, for their own CPD. ie John White and 2/5/14 Alert circulated to John White. Closed 07/05/ /5/14 T Wilburn reviewed alert: Can you please circulate to Jeanette Arnold and the CQC for information only. No further action required as NHS England would have 30/5/14 Alert ciruclated to J Arnold, John White, S Dutton & C Tozer Closed 04/06/2014 6/6/14 Alert reviewed by T Wilburn: I can confirm that there is no further action to be undertaken in terms of distribution, however, could I please ask you to link in with Debbi Scotting in PSHFT to seek assurance that Peterborough Hospital have received the alert and are actioning in accordance with its recommendations. 9/6/14 Alert sent to D Scotting, PSHFT for action. 17/6/14 Response from D Scotting, advised no longer works for PSHFT. 19/6/14 Alert circulated to Carol Pridmore at PSHFT as advised by D Scotting. 19/6/14 Response from Carol Pridmore: I have forwarded to our Chief Pharmacist, either she or I will get back to you with our Trust actions. 20/6/14 RESPONSE FROM PHSFT: We have already responded and liaised with paediatrics as we had an affected baby. The product concerned is the fat component of the intravenous feed given to prem babies who aren't able to be given nutrition orally. It is a feed that is prepared using separate sterile Page 7 of 8

8 CENTRAL ALERTING SYSTEM (CAS) DISTRIBUTION RETURN SLIP ALERT DETAIL: Appendix 2 DATE OF ISSUE: DEADLINE DATE: (all actions to have been completed and forms returned by this date) IMPORTANT ACTION TO BE TAKEN BY: On receipt of this circular, review the alert, its deadline and assess its applicability. Initiate the action described within the alert and sign and return this form to indicate the stage of implementation i.e. all required actions have been taken or are on-going and relevant persons have been notified. It must then be returned to this office by the stated deadline date above. (*please return this slip, even if this alert is not applicable to your service area, thank you) * Important - Please complete all sections below, thank you:- 1. Is this CENTRAL ALERTING SYSTEM (CAS) alert applicable to your service area? (Please identify if applicable or not) YES/NO 2. Has any action been taken (please state in box below)? 3. Are there any outstanding actions (if so, please identify below)? YES/NO (i) Implementation ongoing (identify anticipated implementation date) Anticipated Date 4 Do you perceive a significant risk to patients or staff as a result of this alert? YES/NO Name: Designation.. Practice Address:... Signature:.Date: Please complete and return by the stated deadline date to: Nicola Walker, Risk Administration Assistant, Clinical Risk Team, hosted by Lincolnshire West CCG, Cross O Cliff, Bracebridge Heath, Lincoln, Lincs. LINCOLN, LN4 2HN Tel: (01522) Fax No: or nicola.walker@lincolnshirewestccg.nhs.uk Page 8 of 8