Policy on Learning and Embedding Lessons Arising from Incidents, Claims and Complaints

Transcription

1 Lead Executive Click here t enter text. Plicy n Learning and Embedding Lessns Arising frm Incidents, Claims and Cmplaints Versin Number: V 1 Name f riginatr/authr: Risk Manager Name f respnsible Risk Cmmittee cmmittee: Name f executive lead: Directr f Nursing and Therapies Date V1 issued: March 2013 Last Reviewed: New Plicy Next Review date: March 2016 Scpe: Trust Wide MMHSCT Plicy Cde CO-09 Page 1 f 20

2 Dcument Title / Ref: Dcument Cntrl Sheet Plicy n Learning and Embedding Lessns Arising frm Incidents, Claims and Cmplaints Lead Executive Directr f Nursing and Therapies Directr Authr and Cntact Risk Manager Number Type f Dcument Plicy Brad Categry Crprate Dcument Purpse T achieve cmpliance with the NHS LA Risk Management standard 2 Criterin 6. Scpe Trust Wide Versin number V 1 Cnsultatin Thrugh discussin with the Head f Patient Safety, Head f Cmplaints, PALS and Legal Services and Regulatins, Cmpliance and Head f Quality Imprvement and the Risk Cmmittee and Clinical Gvernance Cmmittees. Apprving Cmmittee Risk Cmmittee Apprval Date February 2013 Ratificatin Trust Management Bard /Operatinal February 2013 and Date Management Team / Cmmittee V1 Valid frm Date March 2013 Current versin is valid frm apprval date Date f Last Review March 2013 Date f Next Review March 2016 Prcedural Dcuments t be read in cnjunctin with this dcument: Trust Risk/Incident/Cmplaints Grading Matrix The Trust Bard Assurance and Escalatin Framewrk (June 2012) Risk Management Strategy. Investigatin f Incidents, Cmplaints and Claims Plicy Incident and Critical Incident (SUI) Plicy, prcedure and Guidance including Data Incidents. DH Central Alerting System (CAS) Plicy Cmplaints Plicy Claims Handling Plicy Learning and Embedding Lessns Arising frm Incidents, Cmplaints and Claims Supprting Staff Invlved in Incidents, Cmplaints and Claims Training Needs Analysis Impact There are n Training requirements fr this prcedural dcument Click here t enter text. Page 2 f 20 Being Open Plicy Financial Resurce Impact There are n Financial resurce impacts Click here t enter text. Dcument Change Histry Changes t this dcument in different versins must be detailed belw. Ratinale fr the change shuld als be given

3 Versin Number / Name f prcedural dcument this supersedes Type f Change i.e. Review / Legislatin / Claim / Cmplaint Date Details f Change and apprving grup r Executive Lead (if dne utside f the frmal revisin prcess) New Plicy New Plicy N/A Versin 1 N/A External references used in the creatin f this dcument: If these include mnitring duties upn the Trust fr this plicy the specific details shuld be recrded n the Mnitring and Cmpliance Requirements sheet NHSLA Risk Management Standards NHS Litigatin... Department f Health: Natinal Quality Bard (2010) Review f early warning systems in the NHS Dr Fster Intelligence (2010) The Intelligent Bard 2010: Patient Experience Health Fundatin (2010) Snapsht Patient Safety: Transfrming rganisatinal appraches t deliver safer patient care Huse f Cmmns (2009) Huse f Cmmns Health Cmmittee: Patient Safety: Sixth Reprt f Sessin , Vlume I Natinal Patient Safety Agency (NPSA) (2004) Seven Steps t Patient Safety Natinal Patient Safety Agency (NPSA) (2010) Never Events: Framewrk Update fr 2010/11: Prcess and actin fr Primary Care Trusts; Update fr January 2012: Never Events List Natinal Patient Safety Agency (NPSA) and NHS Cnfederatin (2008) Briefing 161: Act n reprting Natinal Patient Safety Agency (NPSA) and NHS Cnfederatin (2009) Questins are the answer! Seven questins every bard member shuld ask abut patient safety Patient Safety First (2009) The Hw t Guide fr Implementing Human Factrs in Healthcare Privacy Impact N/a Any issues? N Assessment submitted Fraud Prfing N/a Any issues? N submitted If nt relevant t this prcedural dcument give ratinale: Plicy authrs are asked t cnsider each f the nine prtected characteristics under the Equality Act We expect yu t demnstrate that thrughut the plicy prcess yu have had regard t the aims f the Equality Duty: 1. Eliminate unlawful discriminatin, harassment and victimisatin and any ther cnduct prhibited by the Act; 2. Advance equality f pprtunity between peple wh share a prtected characteristic and peple wh d nt share it; and 3. Fster gd relatins between peple wh share a prtected characteristic and peple Page 3 f 20

4 wh d nt share it. Please prvide a brief accunt f hw yu have dne this, further wrk t be cmpleted and any supprt yu have had in cnsidering the aims and wrking in cmpliance with the Equality Duty. If yu are unclear n hw t d this r wuld like further advice and supprt then yu may cntact quality.admin@mhsc.nhs.uk. It is the respnsibility f the apprving grup t ensure this statement reflects the Trusts bjectives and psitin with cmpliance as set ut within the NHS Equality Delivery System This plicy is brad and the scpe is Trust-wide s cmplies with the Trust s Equality Delivery System In line with the Trust values we may publish this dcument n ur External Website. Is there any reasn yu wuld prefer this is nt dne? It is the Authrs respnsibility t ensure all prcedural dcuments cmply with the Trust values If yu are unclear n any f the requirements in the dcument cntrl sheet then please quality.admin@mhsc.nhs.uk befre prceeding Page 4 f 20

5 Mnitring and Cmpliance Requirements Sheet Fr audit, Registratin and NHSLA purpses all prcedural dcuments must have mnitring requirements r key perfrmance indicatrs set by the authrs, Cmmittees r Lead Directrs. This allws the Trust t rutinely mnitr the effectiveness and impact f their prcedural dcuments n a regular basis. Prcedural Dcument Title: Plicy n Learning and Embedding Lessns Arising frm Incidents, Claims and Cmplaints Des this prcedural dcument ffer supprt r evidence fr the Trusts registered activities and utcmes? Yes Primarily Outcme 16 Assessing and Mnitring Quality Additinal Nt Applicable Additinal Chse an item. Is this an NHSLA Dcument? Yes Which Standard des this relate t? 1 - Gvernance Which Criterin 2/6 Analysis & Imprvement 2/7 Learning Lessns frm Claims Chse an item. If ther Mnitring requirements are necessary i.e. Health & Safety Act and yu shuld include them here and recrd them in the External References sectin Specify where the requirement riginates Minimum Requirement / Standard / Indicatr t be mnitred & Sectin f dcument it appears Level 1 (a) Dcumented prcess f the duties f staff. Level 1 (b) Dcumented prcess f hw Incidents, Cmplaints and Claims are analysed Level 1 (c ) Dcumented prcess f hw the infrmatin is cmbined t prvide a risk prfile fr the rganisatin. Prcess fr mnitring Respnsible Individual / Grup Page 5 f 20 Additinal Details i.e. Sectin number, Cde f Practice Frequency f Mnitring Respnsible Grup fr review f results / actin plan apprval / implementatin Review Risk Manager 3 Yearly Risk Cmmittee Review Review The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager 3 Yearly Risk Cmmittee 3 Yearly Risk Cmmittee Cmments

6 Level 1 (d) Prvide a reprt template which includes qualitative and quantitative analysis Level 1 (e) Dcumented prcess f hw this infrmatin will be shared with relevant individuals r grups. Level 1 (f) Dcumented Prcess f hw actin plans are fllwed up. Level 1 (g) Dcumented prcess fr the timescales fr minimum requirements b) t f) Level 1 (h) Dcumented prcess f hw the Trust mnitrs cmpliance with all f the abve. Level 2 Shw evidence f the implementatin f the dcumented prcess in relatin t: reprts, including qualitative and Review Review Review Review Audit Audit The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager ard The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the 3 Yearly Risk Cmmittee 3 Yearly Risk Cmmittee 3 Yearly Risk Cmmittee 3 Yearly Risk Cmmittee Yearly Risk Cmmittee Yearly Risk Cmmittee Page 6 f 20

7 quantitative analysis Risk Manager hw actin plans are fllwed up. Level 3 Demnstrate evidence f the mnitring f the dcumented prcess in relatin t: reprts, including qualitative and quantitative analysis Audit The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services, Head f Regulatins, Cmpliance and Quality Imprvement and the Risk Manager Yearly Risk Cmmittee hw actin plans are fllwed up. Where the mnitring has identified shrtfalls, demnstrate evidence that changes have been made t address them and system f Cntinuus Imprvement. NB: If yu have selected audit yu shuld cmplete the required audit registratin frm and standards dcument and submit these with yur expected timescales fr cmpleting the audit t quality.admin@mhsc.nhs.uk as sn as pssible and n later than 4 weeks prir t the audit cmmencing. The Grup / Cmmittee shuld als ensure the mnitring wrk is added t their yearly schedule f mnitring and actin lgs as apprpriate. Page 7 f 20

8 Cntents Page Sectin Title Page Number 1 Executive Summary 9 2 Intrductin 9 3 Definitins 10 4 Purpse and Scpe f the Plicy 10 5 Duties All staff The Head f Patient Safety/Head f PALS, 11 Cmplaints and Legal Services 5.3 Directrs and senir management Trust Chief Executive The Trust Cmmittee Structure and Care Grups Serius Incident Requiring Investigatin (SIRI) Cmplaints Mnitring Care Grup Gvernance and Quality meetings Bard Assurance and Escalatins Framewrk 13 6 The Plicy and Prcedural Framewrk 13 7 Risk Reductin measures: 13 8 Trust Recmmendatin Actin Plans and Prcess Trust wide Actin Plans Service r Care Grup Specific Actin Plans 15 9 Further pprtunities fr imprving practice and reducing 15 risk 10 Ensuring that lessns learnt are embedded int everyday 16 practice Appendix Appx 1 Risk/Incidents/Cmplaints Grading Matrix 18 Have yu cnsidered using a flwchart in yur dcument t prvide easy reference fr staff? If yu need supprt in develping a flwchart cntact quality.admin@mhsc.nhs.uk Page 8 f 20

9 Plicy n Learning and Embedding Lessns Arising frm Incidents, Claims and Cmplaints 1. Executive Summary This Plicy is required in rder t achieve cmpliance with the NHS litigatin Authrity Risk Management standard 2 and criterin 6 and Standard 2 Criterin 7. This plicy describes hw the Manchester Mental Health and Scial Care Trust (the Trust) has a cmmitment t cnstantly ensure learning and imprvements t standards f care. The Trust has put in place an effective prcess t reprt, investigate, mnitr and learn frm incidents, cmplaints and claims. One f the key aims f this prcess is t reduce the risk f repeat bth where the riginal incident, cmplaint r claim ccurred and elsewhere in the Trust. The timely and apprpriate disseminatin f learning fllwing an incident, cmplaint r claim is cre t achieving this and t ensure that these lessns are embedded in practice. This plicy als addresses issues related t reductin f risk measures thrugh learning and develping a culture f cntinuus imprvement. 2. Intrductin This plicy describes hw the Manchester Mental Health and Scial Care Trust (the Trust) has a cmmitment t cnstantly ensure learning and imprvements t standards f care. The Trust has put in place an effective prcess t reprt, investigate, mnitr and learn frm incidents, cmplaints and claims. One f the key aims f this prcess is t reduce the risk f repeat bth where the riginal incident, cmplaint r claim ccurred and elsewhere in the Trust. The timely and apprpriate disseminatin f learning fllwing an incident, cmplaint r claim is cre t achieving this and t ensure that these lessns are embedded in practice. Learning fllwing an incident, cmplaint r claim is defined as safety, practice and prcess issues which have cntributed t the incident, cmplaint r claim but frm which thers can learn. Examples f learning are given belw: Slutins t address rt causes which may be relevant t ther teams, services and prvider rganisatins. Gd practice which reduced the ptential impact f the incident, cmplaint r claim. Early detectin r interventin which reduced the ptential impact f the incident. Lessns frm cnducting the investigatin which may imprve the management f investigatins in the future. Page 9 f 20

10 Recmmendatins arise frm the lessns learnt frm investigatins. The implementatin f the recmmendatins int everyday wrking practice cntributes t an embedding f gd practice and an rganisatinal culture f cntinuus imprvement. 3. Definitins An incident is an event which gives rise t, r has the ptential t prduce, unexpected r effects invlving the safety f service users, staff r ther persns. A serius incident (SI) is a Serius Incident Requiring Investigatin (SIRI) r near miss which may require further investigatin including thse reprted via Safeguarding Children and Safeguarding Adults prcedures. A cmplaint is an expressin f dissatisfactin received by the Trust verbally r in writing either directly frm r n behalf f existing r frmer service users, carers, relatives, visitrs r ther users f Trust facilities. A claim is a request fr cmpensatin. Aggregatin f data is data being brught tgether e.g. data frm incidents, cmplaints and claims being brught tgether in ne reprt. 4. Purpse and Scpe f the plicy The plicy utlines: The imprtance f learning lessns frm investigatins t imprve practice and t reduce the risk f further incidents, cmplaints and claims. The systems and structures in place t ensure that lessns are learnt frm investigatins int incidents, cmplaints and claims. The prcess by which the rganisatin ensures that lessns learnt frm investigatins result in recmmendatins which imprve practice and reduce risk. Hw recmmendatins are made available fr scrutiny and mnitring thrugh clinical gvernance structures. Hw Trust staff actively learn frm the recmmendatins arising frm investigatins int incidents, cmplaints and claims. The disseminatin, implementatin and access t this plicy. The prcess fr mnitring cmpliance with the plicy. Page 10 f 20

11 5 Duties This sectin gives an verview f the individual, departmental, and cmmittee rles and levels f respnsibility fr the prcess f learning lessns frm investigatins int incidents, cmplaints and claims and imprving practice in respnse t thse lessns. 5.1 All Staff All Trust staff have a duty t reprt risks, hazards, incidents, accidents, near misses and cmplaints. Trust staff must engage with the investigatin prcesses that fllw. Trust staff have a duty t cntinuusly update and imprve their skills, knwledge and cmpetence in respnse t emerging gd practice and the lessns learnt frm investigatins int incidents, cmplaints and claims. 5.2 The Head f Patient Safety, and Head f PALS, Cmplaints and Legal Services Departments These central Trust departments have a respnsibility t ensure that the learning agenda is prmted at all times. This will be achieved by: Ensuring all incidents, cmplaints and claims are mnitred. Prviding a respnsive and cnsistent service t the Care Grups and directrates. Ensuring that the electrnic reprting system (DATIX) is used t its full ptential t enable a thrugh analysis f the antecedents, causes and utcmes f incidents, cmplaints and claims. Prcessing infrmatin cnsistently and precisely and presenting it in a timely, relevant and meaningful way. This infrmatin can be presented thrugh, fr example feedback t Care Grups and teams, annual reprts and aggregated reprts. (fr further infrmatin refer t the Plicy n the Prcess fr the Aggregatin f Incidents, Claims and Cmplaints). Prmptly identifying themes and pssible prblem areas. Ensuring systems are in place t identify learning pprtunities, themes and trends are f value t the Trust. 5.3 Directrs and Senir Management Directrs and senir managers must ensure that cmmunicatin and management systems are in place t enable frnt line staff t prvide care as safely as pssible in line with Trust plicies and prcedures. Directrs and senir managers must acknwledge, supprt and create pprtunities fr cntinuus imprvement in respnse t the lessns learnt frm investigatins, inquiries and reviews. Directrs and senir managers shuld supprt staff in the fllw-up and implementatin f initiatives and slutins identified by investigatins, inquiries and reviews. Directrs and senir managers have an bligatin t ensure that Page 11 f 20

12 recmmendatins arising frm the lessns learnt frm investigatins int incidents, cmplaints and claims adhere t the SMART principles i.e. they shuld be: Specific Measurable Achievable Realistic and Timely Directrs and senir managers shuld als be pen t change and maintain a Trust wide perspective by supprting the transfer and embedding f lessns acrss Care Grups. 5.4 Trust Chief Executive The Chief Executive is ultimately respnsible fr ensuring that incidents, cmplaints and claims are effectively investigated with resulting active learning. This will prmte Trust accuntability and penness and assist in fulfilling the Trust s statutry respnsibilities. 5.5 The Trust cmmittee structure and Care Grups The Trust cmmittee structure and Care Grups are established t facilitate Trust wide level representatin and sharing f minutes and representatin. The Clinical Gvernance, Risk cmmittee and Patient Experience Cmmittees perate t cmmn terms f reference which encmpass the requirement fr cntinuus learning t imprve practice and reduce risk. The Clinical Gvernance and Risk cmmittees are respnsible fr ratifying, planning the implementatin and mnitring f lcal and Trust wide recmmendatins. The Clinical Gvernance, Risk and Patient Experience Cmmittees are respnsible fr acknwledging and accepting the findings and lessns learnt frm investigatins int incidents, cmplaints and claims. The Clinical Gvernance and Risk cmmittees are respnsible fr finalising and agreeing SMART recmmendatins and ratifying actin plans t reduce risk and imprve practice. The implementatin f the actin plans is mnitred by the Clinical Gvernance and Risk and Patient Experience Cmmittees 5.6 Serius Incident Requiring Investigatins (SIRI) Lessns learnt and the SMART recmmendatins arising frm the SIRIs are scrutinised and agreed at the High Level Investigatin Panel (HLIP). Recmmendatins frm each SIRI are entered in an actin plan. An actin Plan Manager takes the lead in c-rdinating the cmpletin f the actin plan. 5.7 Cmplaints Mnitring Cmplaints are mnitred by the Head f Pals, Cmplaints and Legal Services. The Head f Pals, Cmplaints and Legal Services reviews lcal cmplaint investigatins and the respnses which fllw. Page 12 f 20

13 Lessns learnt and the SMART recmmendatins arising frm these are scrutinised and agreed by investigatrs and Service Managers. These recmmendatins are put int an actin plan. All learning frm Actin Plans are reprted t the Patient Experience Cmmittee thrugh the Cmplaints, PALs and Cmpliments Quarterly Reprt. These reprts are cascaded t the Care Grups wh discuss themes and learning and disseminate t teams/ward. 5.8 Care Grup Gvernance and Quality meetings Each Care Grup hlds a Gvernance and Quality meetings where the actin plans utlined abve are shared and the lessns learned are embedded in practice. The actin plans are active dcuments which identify the cntext f the recmmendatin, clear gals and implementatin plans, fr example timescales and the names and psitins f staff delegated t lead the changes. The actin plans are wned by the Actin Plan Managers wh c-rdinates the Leads fr each actin. The Risk Cmmittee and Patient Experience Cmmittee has the respnsibility t mnitr and review the implementatin f the recmmendatins. The actin plans als identify the agreed audits t assess whether the imprvements have been fully embedded. It is essential that the Actin Plan Manager identified t drive the changes frward have sufficient authrity and experience. In mst instances the Care Grup General Managers t versee the implementatin prcess in cnjunctin with the Gvernance and Quality meetings wh are respnsible fr assessing and reprting n the prgress f implementatin and maintaining the actin plans. 5.9 Bard Assurance and Escalatin Framewrk The Trust Bard Assurance and Escalatin Framewrk (June 2012) will be the prcess used t assured that lessns are learnt and imprvements made in respnse t investigatins int incidents, cmplaints and claims thrugh the Trust Quality Bard. 6. The plicy and prcedural framewrk The Trust perates t an established framewrk f plicy and prcedure which gverns all activity. All plicies and prcedures are mtivated by the need t prmte the safety and wellbeing f Trust patients. A list f prcedural dcument t be read in cnjunctin with this plicy is given at the frnt f the dcument. The plicies give details f the Trust investigatin prcesses and methdlgy undertaken in respnse t incidents, cmplaints and claims and the reprting systems that fllw. 7. Risk reductin measures: Identifying recmmendatins t imprve practice and reduce risk Thrugh, timely and prprtinate investigatins using rt cause analysis will help t identify the lessns learnt frm incidents, cmplaints and claims. The Investigatin f Incidents, Cmplaints and Claims Plicy details the types and methdlgy f investigatins that are undertaken in respnse t Trust incidents, cmplaints and claims. Page 13 f 20

14 The lessns learnt frm investigatins are translated int recmmendatins t help imprve practice and reduce the risk f repeat. Recmmendatins are either targeted lcally fr example t address prblems in a particular team r aimed Trust wide. External rganisatins are als cmmissined t undertake investigatins and reviews f Trust serius incidents and cmplaints. Examples include: The Care Quality Cmmissin independent review f Trust cmplaint investigatins. Independent investigatin teams, fr example thse cmmissined by the Strategic Health Authrity under Health Service Guidance (HSG) 94(27). Death in Custdy incidents within the Prisn Healthcare Grup These investigatins and reviews will ften prvide recmmendatins t help imprve practice. These recmmendatins can be lcal r Trust wide. The Trust als prvides infrmatin abut incidents, cmplaints and claims t external rganisatins as part f their investigatins r reviews. These rganisatins include the: Lcal Child Safeguarding Bards child-safeguarding incidents. Lcal Authrities adult safeguarding incidents. Medicines and Healthcare prducts Regulatry Agency patient safety incidents. Health and Safety Executive RIDDOR reprtable incidents. The findings f the investigatins r reviews ften result in additinal recmmendatins t the Trust t help imprve practice. These recmmendatins can be lcal r Trust wide. Published reprts f investigatins and reviews int the practice f external rganisatins als give recmmendatins which can be transferred and implemented in the Trust t help imprve practice. These include investigatins cmmissined by Strategic Health Authrities under HSG 94(27) and investigatins and reviews undertaken by the Care Quality Cmmissin. 8. Trust recmmendatin actin plans and the prcess fr implementing risk reductin measures as a result f individual and aggregated analysis f incidents, cmplaints and claims Risk reductin measures are part f the actin planning prcess and are reflected in the actin plans and the risk registers t cntrl r reduce the level f risks with the ultimate aim t eliminate risk. Actin plans are active dcuments which identify clear gals and implementatin plans fr example timescales and the names and psitins f staff delegated t lead the changes. Page 14 f 20

15 8.1 Trust-wide Actin Plans The Patient Safety and the Regulatin, Cmpliance and Quality Imprvement Teams have an verview f all Trust recmmendatins, based n individual and aggregated analysis f incidents, cmplaints and claims, which are held n a Trust-wide actin plan. The actin plan is shared with the Care Grup Gvernance and Quality meetings. The actin plan is an active dcument which is wned by the Trust Directr f Nursing and Therapies and the Head f Patient Safety. The actin plan is mnitred at the Trust Clinical Risk Cmmittee, published with the quarterly Quality Gvernance reprt (this reprt is described in detail in the Plicy n the Prcess fr the Aggregatin f Incidents, Claims and Cmplaints). 8.2 Service r Care Grup specific actin plans The actin plans t address recmmendatins that are service r Care Grup specific are wned by the General Managers f the Care Grup and it is the respnsibility f the Care Grup t discuss, mnitr and review the implementatin f the recmmendatins. 9. Further pprtunities fr imprving practice and reducing risk There are further pprtunities t prmte a learning culture and imprve patient safety. These pprtunities include: Infrming the Trust Learning and Develpment Department f any instances where adjustments, in respnse t lessns learned, shuld be made t the cntent f training curses (Assciate Directr f Learning and Develpment). Infrming plicy wners f any recmmendatins arising frm the investigatin f an incident, cmplaint r claim t amend r revise a Trust plicy r prcedure (Head f Patient Safety / Head f Regulatins, Cmpliance and Quality Imprvement). Effectiveness study days and Cnsultant Study days: The Patient Safety, Cmplaints, PALS and Legal Services and Regulatins, Cmpliance and Quality Imprvement Departments can prepare and present fcussed reprts n key patient safety issues, fr example, reprts are prepared and presented n these study days, particular themes arising frm the investigatin f Incidents. Care Grup training events: The Head f Patient Safety, Head f Cmplaints, PALS and Legal Services and Head f Regulatins, Cmpliance and Quality Imprvement present infrmatin n lessns learnt and themes arising frm incidents, Claims and Cmplaints which have happened in the Trust and elsewhere. The Annual Wrld Suicide Preventin Day event: Presentatins are given n themes and learning arising frm investigatins int patient suicides. The theme frm lessns Learned frm the review f Suicide investigatins are als shared n the Trust Intranet. Ad hc reprts, presentatins and prblem slving are als prvided where necessary and upn request, fr example where themes and trends have Page 15 f 20

16 ccurred in a particular envirnment. The wrk f the Trust Suicide Preventin Grup is psted n the Trust Suicide Preventin site n the Intranet. The Patient Safety, Cmplaints and Claims reprts are available n SharePint and signpsted fr staff and regularly updated. The sites cntain key infrmatin abut the patient safety agenda and give up t date infrmatin which is presented in an easy t read and straightfrward frmat. Training resurces are als upladed n the SharePint site. The quarterly Learning Lessns reprt is circulated electrnically t all staff. This drives the patient safety agenda and gives clear infrmatin abut pprtunities t imprve and change practice in respnse t investigatins int incidents, cmplaints and claims. Alerts frm the Department f Health Central Alerts System (CAS) in respnse t urgent patient safety issues are systematically circulated acrss the Trust (Refer t the CAS Plicy). 10. Ensuring that lessns learnt are embedded int everyday practice The Trust will use the fllwing methds t ensure that lessns learnt are embedded int everyday practice: All incidents, cmplaints and claims are mnitred by the respective department i.e. Patient Safety Department, PALS, Cmplaints and Legal Services Department and Regulatin, Cmpliance and Quality Imprvement Department. The Clinical Gvernance, Risk Cmmittee and Patient Experience Cmmittee mnitr the actin plans as identified in sectin 5 abve. Feedback will be given t the Clinical Gvernance, the Risk Cmmittee and Patient Experience Cmmittee n the prgress made in implementing changes by the General Managers f the Care Grups. The Risk Cmmittee will mnitr whether recmmendatins arising frm investigatins and reviews are being disseminated and acted upn acrss the Trust and whether imprvements are embedded int everyday practice. Planned lcal and Trust audits will be undertaken t assess whether learning has been embedded int everyday practice. The annual staff and patient surveys will be reviewed fr infrmatin relating t patient safety. The Regulatin, Cmpliance and Quality Imprvement Department, will facilitate audits f changes in practice in respnse t the lessns learnt and recmmendatins as part f the annual audit cycle. Lcal audits will be undertaken t assess whether learning has been embedded int everyday practice. Page 16 f 20

17 Cmparisn data with previus year n year incidents, cmplaints and claims will be highlighted in all internal reprts. This will assist in identifying whether changes are being made t practice and whether the changes are having an effect n the frequency and types f incidents, cmplaints and claims. Page 17 f 20

18 APPENDIX 1 Risk/Incidents/Cmplaints Grading Matrix Table 1 Cnsequence scres Cnsequence scre (severity levels) and examples f descriptrs Impact n the safety f patients, staff r public (physical/psychlgical harm) Dmains Negligible Minr Mderate Majr Catastrphic Minimal injury requiring Minr injury r illness, Mderate injury requiring Majr injury leading t lng-term Incident leading t death n/minimal interventin requiring minr interventin prfessinal interventin incapacity/disability r treatment. N time ff wrk Requiring time ff wrk fr >3 days Increase in length f hspital stay by 1-3 days Requiring time ff wrk fr 4-14 days Increase in length f hspital stay by 4-15 days Requiring time ff wrk fr >14 days Increase in length f hspital stay by >15 days Multiple permanent injuries r irreversible health effects An event which impacts n a large number f patients RIDDOR/agency reprtable incident Mismanagement f patient care with lng-term effects Quality/cmplaints/audit Peripheral element f treatment r service subptimal Infrmal cmplaint/inquiry Overall treatment r service subptimal Frmal cmplaint (stage 1) Lcal reslutin Single failure t meet internal standards Minr implicatins fr patient safety if unreslved An event which impacts n a small number f patients Treatment r service has significantly reduced effectiveness Frmal cmplaint (stage 2) cmplaint Lcal reslutin (with ptential t g t independent review) Repeated failure t meet internal standards Nn-cmpliance with natinal standards with significant risk t patients if unreslved Multiple cmplaints/ independent review Lw perfrmance rating Critical reprt Ttally unacceptable level r quality f treatment/service Grss failure f patient safety if findings nt acted n Inquest/mbudsman inquiry Grss failure t meet natinal standards Human resurces/ rganisatinal develpment/staffing/ cmpetence Statutry duty/ inspectins Adverse publicity/ reputatin Shrt-term lw staffing level that temprarily reduces service quality (< 1 day) N r minimal impact r breech f guidance/ statutry duty Rumurs Ptential fr public cncern Reduced perfrmance rating if unreslved Lw staffing level that reduces the service quality Breech f statutry legislatin Reduced perfrmance rating if unreslved Lcal media cverage shrt-term reductin in public cnfidence Elements f public expectatin nt being met Majr patient safety implicatins if findings are nt acted n Late delivery f key bjective/ service due t lack f staff Unsafe staffing level r cmpetence (>1 day) Lw staff mrale Pr staff attendance fr mandatry/key training Single breech in statutry duty Challenging external recmmendatins/ imprvement ntice Lcal media cverage lng-term reductin in public cnfidence Uncertain delivery f key bjective/service due t lack f staff Unsafe staffing level r cmpetence (>5 days) Lss f key staff Very lw staff mrale N staff attending mandatry/ key training Enfrcement actin Multiple breeches in statutry duty Imprvement ntices Lw perfrmance rating Critical reprt Natinal media cverage with <3 days service well belw reasnable public expectatin Nn-delivery f key bjective/service due t lack f staff Onging unsafe staffing levels r cmpetence Lss f several key staff N staff attending mandatry training /key training n an nging basis Multiple breeches in statutry duty Prsecutin Cmplete systems change required Zer perfrmance rating Severely critical reprt Natinal media cverage with >3 days service well belw reasnable public expectatin. MP cncerned (questins in the Huse) Ttal lss f public cnfidence Business bjectives/ prjects Insignificant cst increase/ schedule slippage <5 per cent ver prject budget Schedule slippage 5 10 per cent ver prject budget Schedule slippage Nn-cmpliance with natinal per cent ver prject budget Schedule slippage Key bjectives nt met Incident leading >25 per cent ver prject budget Schedule slippage Key bjectives nt met Page 18 f 20

19 Finance including claims Small lss Risk f claim remte Lss f per cent f budget Claim less than 10,000 Lss f per cent f budget Claim(s) between 10,000 and 100,000 Uncertain delivery f key bjective/lss f per cent f budget Claim(s) between 100,000 and 1 millin Purchasers failing t pay n time Nn-delivery f key bjective/ Lss f >1 per cent f budget Failure t meet specificatin/ slippage Lss f cntract / payment by results Claim(s) > 1 millin Service/business interruptin Envirnmental impact Lss/interruptin f >1 hur Minimal r n impact n the envirnment Lss/interruptin f >8 hurs Minr impact n envirnment Lss/interruptin f >1 day Mderate impact n envirnment Lss/interruptin f >1 week Majr impact n envirnment Permanent lss f service r facility Catastrphic impact n envirnment Chse the mst apprpriate dmain fr the identified risk frm the left hand side f the table Then wrk alng the clumns in same rw t assess the severity f the risk n the scale f 1 t 5 t determine the cnsequence scre, which is the number given at the tp f the clumn. Table 2 Likelihd scre (L) What is the likelihd f the cnsequence ccurring? The frequency-based scre is apprpriate in mst circumstances and is easier t identify. It shuld be used whenever it is pssible t identify a frequency. Likelihd scre Descriptr Rare Unlikely Pssible Likely Almst certain Frequency Hw ften might it/des it happen This will prbably never happen/recur D nt expect it t happen/recur but it is pssible it may d s Might happen r recur ccasinally Will prbably happen/recur but it is nt a persisting issue Will undubtedly happen/recur,pssibly frequently Nte: the abve table can be tailred t meet the needs f the individual rganisatin. Sme rganisatins may want t use prbability fr scring likelihd, especially fr specific areas f risk which are time limited. Fr a detailed discussin abut frequency and prbability see the guidance ntes. Likelihd Likelihd scre Rare Unlikely Pssible Likely Almst certain 5 Catastrphic Majr Mderate Minr Negligible Table 3 Risk scring = cnsequence x likelihd ( C x L ) Nte: the abve table can t be adapted t meet the needs f the individual trust. Fr grading risk, the scres btained frm the risk matrix are assigned grades as fllws 1-3 Lw Risk 4-6 Mderate Risk 8-12 High Risk Extreme Risk When rating a risk we grade the wrst case scenari and multiply the impact by the likelihd t get the rating Page 19 f 20

20 Instructins fr use 1 Define the risk(s) explicitly in terms f the adverse cnsequence(s) that might arise frm the risk. 2 Use table 1 (page 13) t determine the cnsequence scre(s) (C) fr the ptential adverse utcme(s) relevant t the risk being evaluated. 3 Use table 2 (abve) t determine the likelihd scre(s) (L) fr thse adverse utcmes. If pssible, scre the likelihd by assigning a predicted frequency f ccurrence f the adverse utcme. If this is nt pssible, assign a prbability t the adverse utcme ccurring within a given time frame, such as the lifetime f a prject r a patient care episde. If it is nt pssible t determine a numerical prbability then use the prbability descriptins t determine the mst apprpriate scre. 4 Calculate the risk scre the risk multiplying the cnsequence by the likelihd: C (cnsequence) x L (likelihd) = R (risk scre) 5 Identify the level at which the risk will be managed in the rganisatin, assign pririties fr remedial actin, and determine whether risks are t be accepted n the basis f the clur bandings and risk ratings, and the rganisatin s risk management system. Include the risk in the rganisatin risk register at the apprpriate level. Based n NPSA Mdel Matrix Page 20 f 20