Title Description of Document Scope Author and designation Equality Impact Assessment (EIA) Associated Documents Supporting References Learning from Incidents, Complaints and Claims This policy identifies how the analysis of incidents, complaints, and claims is aggregated to learn lessons and improve practice and procedures. It describes the additional sources of information used including Pals and recommendations from Root Cause Analysis. Ensuring a co-ordinated approach where information is triangulated with other performance and early warning measures reduces the risk of events being seen in isolation. It assists in providing assurance to patients, the public and other stakeholders that systems for managing risk within Norfolk Community Health & Care NHS Trust (NCH&C) are in place, robust and working This policy applies to all NCH&C staff who report incidents, investigate complaints or are involved in the management of claims to assist understanding of how the information is used to improve patient safety and support learning. Vivian Whittaker, Assistant Director Risk Management and Information Governance Positive impact Risk Strategy; Incident Reporting, Investigation & Management Policy; Claims Policy; Complaints Policy National Health Service Litigation Authority: Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health and Learning Disability Services and Independent Sector Providers of NHS Care 2011/12 NHSLA Risk Management Standards / CQC Requirements Consultation or Development Process Training Implications Process for Monitoring Compliance Duties, Accountability and Responsibility Dissemination NHSLA Standard 5.6 & 5.7 CQC Outcome 17 Regulation 19 Staff involved in managing complaints, claims and incidents Staff required to produce aggregated reports are informed how to do so and the required format as part of local induction to the Quality & Risk team Section 10 Section 4 and Section 5 This procedural document is published on NCH&Cs Intranet. Staff are informed of this and any changes or updates via the NCH&C Page 1 of 12 ver 1.0 22 March 2012
Monthly Briefing Exchange, Weekly Messages or equivalent. Is there any reason why any part of this document should not be available on the public web site? Yes No Approval Process Ratification Process Review Arrangements This policy was approved by the Trust Management Team This policy was ratified by the Quality & Risk Assurance Committee on 14 March 2012 April 2014, or sooner should legislation require it, by the Assistant Director Risk Management. Date of issue March 2012 Archiving Arrangements Previous versions of this policy are archived at G:\ARCHIVE NCH&C Page 2 of 12 ver 1.0 22 March 2012
Learning From Incidents, Complaints and Claims Contents Section Page Document Control 1 Introduction 5 2 Purpose 5 3 Definitions 5 4 Duties 6 5 Roles of Trust Committees 9 6 Coordination and content of aggregated reports 9 7 Distribution of aggregated reports to share learning 11 8 Process for Implementing risk reduction measures 11 9 Learning and promoting improvements in practice 11 10 Monitoring Compliance 12 NCH&C Page 3 of 12 ver 1.0 22 March 2012
Document Control Version Date Author Status Comment 0.1 March V Whittaker Draft For approval 2012 0.2 March 2012 Jo Hardcastle Draft Updated front sheet and amended formatting in line with policy for 1.00 22 March 2012 Quality & Risk Assurance Committee Ratified procedural documents Ratified by Quality & Risk Assurance Committee NCH&C Page 4 of 12 ver 1.0 22 March 2012
1. Introduction 1.1 The safety of patients, staff and visitors is a key priority within Norfolk Community Health & Care NHS Trust (NCH&C). A collaborative approach to the analysis of incidents, complaints and claims, as well as any additional internal sources of information such as PALS or Root Cause Analysis (RCA) reports, ensures that wherever possible the organisation learns from events that occur. 1.2 The analysis of aggregated data can provide an opportunity for proactive risk management, supporting learning from events that have happened and looking ahead to see how the same events can be prevented or controlled in the future. 2. Purpose 2.1 This policy identifies the process to ensure a systematic approach to the aggregation and analysis of incidents, complaints and claims. 2.2 It describes the process for this information to be triangulated with other sources by which risk and safety are measured within the Trust, including but not exclusive to Root Cause Analysis and the Early Warning Trigger Tool (EWTT). 2.3 It describes the process to ensure that NCH&C ensures this information is used to learn lessons, to share the learning, and to improve and make changes to practice. 2.4 It describes the whole-systems approach required to ensure this is effective, linking into the established management, governance, reporting and escalation processes in place. 3. Definitions 3.1 Incident - any event or circumstance that could have or did lead to unintended or unexpected, harm, loss or damage. These may be clinical or non clinical and can affect staff patients or visitors while on the Trust premises. 3.2 Complaint - an expression of dissatisfaction with an aspect of the Trust s service to which the complainant requires a response. 3.3 Claim legal process to identify breach of duty and causation as a result of an act or omission including action taken under the Pre-action Protocol for the Resolution of Clinical Disputes as set out in the Civil Procedure Rules 1998(amended) 3.4 Root cause analysis (RCA) - is a structured investigation which aims to identify the true cause of a problem and the actions that are necessary to either eliminate or significantly reduce the risk NCH&C Page 5 of 12 ver 1.0 22 March 2012
3.5 Aggregated data analysis - Data from incidents, complaints and claims which have been analysed both separately and together, and in a number of different ways e.g. by specialty, cause, etc. to determine a comprehensive risk profile of the organisation 3.6 Learning using information from the analysis and aggregation of events and Root Cause analysis to inform future practice to reduce the risk of similar events occurring. 3.7 Deficits failures in compliance with the requirements of this policy as identified through the monitoring process 4. Duties within the Organisation 1 4.1 Chief Executive The Chief Executive is accountable to the Trust Board for ensuring that governance structures are in place to support reporting of aggregated analysis of incidents, complaints and claims including monitoring of actions required and taken. The structures support sharing of learning across the organisation to improve future practice and reduce the risk of similar events occurring. The structure for Risk Management is given in the Risk Strategy and aligns with the existing decision making, governance and reporting processes within NCH&C to facilitate this process. 4.2 Executive Team The Executive Team are responsible for ensuring that learning from aggregated incidents, complaints, claims and RCA s are reviewed as part of the day to day business of the Trust. The information is included in the strategic performance review meetings and where appropriate, individual direrctors raise issues or defecits with their relevant Assistant Directors, Deputies and executive colleagues. 4.3 Nominated Directors 4.3.1 The Medical Director is responsible for ensuring that learning is cascaded to the medical staff within the Trust and across the wider health partnership where appropriate. As a Community Trust, NCH&C aims to share learning with, and to learn from, GP colleagues 4.3.2 The Director of Quality, Risk & Executive Nurse is responsible for ensuring learning is shared with nursing, therapy and clinical teams to support changes to practice where required. 4.3.3 The Director of Operations is responsible for ensuring that the structures in place across the clinical teams supports early identification of risk, encourages reporting and links into the wider learning, governance and assurance processes of the Trust. 4.4 Assistant Directors 1 Aggregated analysis is part of the wider risk management framework - See Risk Strategy NCH&C Page 6 of 12 ver 1.0 22 March 2012
4.4.1 Assistant Directors are responsible for ensuring that the local team governance structures enable aggregated learning and data analysis from their own incidents, complaints, claims and RCA s as well as those from other teams. 4.4.2 They ensure that aggregated analysis reports are discussed at their locality business meetings or equivalent in line with their internal clinical governance structures. 4.4.3 They review issues raised and assess their applicability to the service areas within their remit. 4.4.4 They ensure any relevant points are discussed by the locality business meetings, assessed for deficits and added to the risk register or escalated to the corporate risk register as appropriate in line with the Risk Management Strategy. 4.4.5 Where actions are required to mitigate risk identified from aggregated analysis they ensure they are monitored by the business unit, escalating within the governance structure to the Clinical Management Team, strategic performance review, Trust Management Team or relevant Director as appropriate. 4.5 Quality & Risk Manager 4.5.1 The Quality & Risk Manager is responsible for ensuring analysis of reported incidents as identified in the Incident Reporting, Investigation & Management Policy occurs. 4.5.2 Separate analysis and themes identified from reported incidents are aggregated with the claims and complaints analysis to identify learning points, including recommendations from Root Cause Analysis. 4.5.3 They oversee preparation of the report on this data to the Quality & Risk Assurance Committee quarterly as per the committee workplan. 4.5.4 They ensure risks are updated on the local and corporate risk registers and escalated appropriately 4.6 Complaints and Claims Manager 4.6.1 The Complaints and Claims Manager ensures data from complaints and claims is analysed as identified in the Complaints Policy and the Claims Policy. They ensure this information is combined into the aggregated risk report to the Quality & Risk Assurance Committee quarterly. 4.7 Health Records Manager 4.7.1 The Health Records Manager ensures analysis of data from requests for disclosure is included in the quarterly reports as these can be an early indicator that systems and processes that the Trust believes to be working well, may not be. NCH&C Page 7 of 12 ver 1.0 22 March 2012
4.8 PALS Manager 4.8.1 The PALS Manager ensures PALS referrals are analysed as per the PALS Protocol and identifies any areas which may need to be linked into the aggregated analysis report. 4.9 Assistant Director Risk Management & Information Governance 4.9.1 The Assistant Director for Risk Management & Information Governance is responsible for ensuring that the process is in place for the Quality & Risk Team to aggregate and analyse information and to link this back into the local and strategic governance and reporting systems of the Trust. 4.9.2 They liaise with the Trust Secretary and other Assistant Directors and departments e.g. performance team, to ensure this occurs, that actions to support improvement are documented. 4.9.3 They oversee the corporate risk register and ensure relevant learning from aggregation and analysis is escalated to the Trust Secretary for possible inclusion in the Board Assurance Framework as appropriate. 4.10 Locality Managers, Modern Matrons, Team Leads 4.10.1 Locality Managers, Modern Matrons & Team leaders are responsible for ensuring their staff report incidents, investigate complaints thoroughly and participate in completion of Root Cause Analysis as appropriate. Without reporting and investigation there is no data on which analysis and aggregation can occur. 4.10.2 They ensure they have a process in place to discuss risk reports received including aggregated reports on a monthly basis. 4.10.3 Where changes to practice are required this must be escalated to the locality meetings and through the management structure to ensure appropriate support is provided to do so, and to assess whether action required relates to individual services or teams or needs a trust wide approach. 4.10.4 Where additional risk is identified this must be documented on the local risk register, as this supports the review in 4.10.3, and escalation to the Corporate risk register if a Trust wide approach is required. 4.11 Clinical and corporate Staff 4.11.1 Clinical and corporate staff are responsible for reporting incidents, investigating complaints and cooperating with claims and root cause analysis investigations. 4.11.2 They are responsible for ensuring they review the monthly reports provided centrally on aggregated data within their specialty, team or locality meetings. NCH&C Page 8 of 12 ver 1.0 22 March 2012
4.11.3 They are responsible for reviewing the learning identified to assess if changes or improvements to the delivery of care or clinical practice is required 5 Roles and Responsibilities of Trust Committees 5.1 Trust Board Trust Board receives suitable and sufficient information through the governance and reporting systems in place from its assurance committees to enable it to be assured that aggregated analysis supports organisational learing to reduce risk. 5.2 Quality & Risk Assurance Committee The Quality & Risk Assurance Committee receives a summary report of aggregated analysis quarterly, the learning identified and action taken to improve practice and mitigate identified risk. 5.3 Trust Management Team The Trust Management Team receives reports on aggregated analysis as part of the monthly review of the Corporate Risk register. It supports additional actions required to improve practice or effect change as a result of any deficits identified from the aggregated analysis. It reviews required actions, recommendations, learning or potential impact on operational service delivery. 5.4 Locality Business Unit meetings Review the aggregated reports and assess whether risks are incorporated into the risk registers or changes to practice are required 6 Co-ordination and content of Reports 6.1 Reports are presented in a quantitative and qualitative format to enable current data to be compared with historical data. This is in the form of visual run charts and graphs to present data over time and to support comparison and identification of any common themes or unexpected events. 6.1 Aggregated reports are reviewed monthly by the locality teams, quarterly by the Quality & Risk Committee and annually by Trust Board. The purpose is to assess the effectiveness of actions taken to reduce the risks from incidents, complaints and claims. 6.2 As review takes place across the Trust at team, locality, corporate, assurance and Trust Board level, this supports learning at each level, providing a forum for discussion in line with the requirements of the Risk Strategy, the governance and decision making structures across NCH&C. 6.3 This complements other risk review and escalation processes, as described in the Assurance & Escalation Framework through the local, corporate risk registers to the Board Assurance framework. NCH&C Page 9 of 12 ver 1.0 22 March 2012
6.4 The following table summarises the information on which the aggregated analysis occurs. It does not replace the separate analysis and reporting which occurs monthly but intends to identify common factors across the incident, complaints and claims systems which may otherwise be missed. It also provides a cross check against recommendations from the RCA s and Pals reports to identify any common contributory factors. Table 1. Content and reporting Minimum content of report includes aggregation of: Incidents Pals All reported incidents graded by level of harm, by team, specialty, location, type, category, severity, against in patient bed days. This includes near misses as well as actual events and those occurring in the community setting RCA Root causes identified, Contributory Factors, Recommendations, lessons learned Complaints All medium to high risk complaints by team, specialty, location, type, category, number linked to previous incidents if any Claims Number of new claims, learning from closed cases, preliminary assessment of claims, court orders, coroners cases, requests for disclosure by unit, specialty, location, type, category, incident date, number linked to previous incident and/or complaint Any issues or other information the Pals Manager identifies as relevant to include Actioned By Risk Manager Risk Manager Complaints & Claims Manager Complaints & Claims Manager Pals Manager Summary aggregated report goes to: 1.Assistant Directors monthly for review at Locality meetings to identify outcomes of analysis, implementation and review of action plans 2.Quality & Risk Assurance Committee quarterly to provide assurance on progress against actions 3. Trust Board annually to confirm review process in place and working. 6.5 Information included in the reports is taken from the Datix system and paper files. 6.6 It is anonymised prior to analysis and patient/staff identifiable data removed. Where the nature of the event makes the person identifiable even when anonymised this should not prevent the aggregation occurring but may require removal prior to sharing learning more widely. Advice in this situation must be sought from the Data Protection Officer. 6.7 Any other key themes or trends from incidents, complaints and claims as identified in the monthly Quality & Risk reports are cross referenced into the report. Aggregated analysis occurs bimonthly. 6.8 Outcome of analysis must be mapped to reported high risks already on the risk registers and actions already taken to control these risks included in the report to prevent duplication. 6.9 The aggregated report is based on the categories identified in the table above and include both qualitative and quantitative analysis where appropriate and identify the source of the data. 6.10 Data is compared and contrasted to identify similarities and differences. This includes trends across and between the areas and explanations of what Are near misses in one area comparable to actual events in other areas? Can action be taken to prevent those near misses escalating into actual events? NCH&C Page 10 of 12 ver 1.0 22 March 2012
7 Distribution of aggregated reports to share learning 7.1 Internal Committees/Groups Reports are distributed as outlined in Table 1. The nominated committees are part of the risk management structure given in the Risk Strategy and the managers are senior staff, authorised to manage risk within their areas as part of their roles and responsibilities. Reports on individual service analysis are sent monthly to clinical teams and the analysis report is distributed to these areas in the same way. 7.1 External Committees/Groups To promote learning from analysis, aggregated reports are shared with identified external partners and/or commissioned services as required and summarised to support learning in external reports e.g. Quality Account. Lessons from aggregated learning are shared at regional and local fora and used to inform cross organisational working e.g as part of emergency planning, network meetings to support patient safety initiatives and share best practice across Norfolk. 8 Process for Implementing Risk Reduction Measures 8.1 Recommendations are reviewed by the Assistant Directors to identify those which are relevant to their services or from which learning is identified. 8.1 These are discussed at the locality meetings to scope and develop action plans which identify what changes are required, how these are to be taken forward, how they will be implemented and monitored locally. 8.2 Recommendations not applicable are documented as such as part of the discussion. Where services identify that a risk needs to be added to the local risk register this is done as per the Risk Management Strategy. 9 Learning and Promoting Improvements in Practice 9.1 A summary of the learning identified must be publicised in a variety of formats including but not exclusively: 9.1.1 on the Risk Management web page 9.1.2 In the weekly briefing 9.1.3 Incorporated into the quarterly learning events attended by internal and external stakeholders 9.1.4 Into risk management training and development programmes NCH&C Page 11 of 12 ver 1.0 22 March 2012
10 Monitoring Compliance with this policy 10.1 Process for Monitoring Compliance What Responsibility How Reported to Report content for evidence of aggregation Audit team Audit Quality & and frequency of completion Risk Compliance with minimum content Assurance requirement Committee Receipt by relevant committees as per workplan or as identified in this policy Evidence of sharing learning with other individuals or groups and process used Evidence of additional risks appropriately included on risk registers as a result of the report Number of action plans with actions outstanding at due date Risk Manager Audit Quality & Risk Assurance Committee When Annually Twice a year Wherever possible, the results of these audits must link back to the existing KPI monitoring process already in place. NCH&C Page 12 of 12 ver 1.0 22 March 2012