Policy for the Analysis and Improvement Following Incidents, Complaints and Claims

Policy for the Analysis and Improvement Following Incidents, Complaints and Claims Exec Director lead Author/ lead Feedback on implementation to Deputy Chief Executive Clinical Risk Manager Clinical Risk Manager Date of draft January 2013 Consultation period Feb 2013 Date of ratification March 2013 Ratified by Executive Directors Date for review Reviewed January 2014 Target audience All Trust staff (including staff seconded into or working in Trust services) and the Trust Board This is a new policy which is stored on the SHSC Trust intranet. Policy for the Analysis and Improvement following incidents, claims and complaints Page 1 of 16

Contents: Section Page 1 Introduction 3 2 Purpose of this policy 3 3 Duties 3 4 Specific details 4 5 Dissemination, storage and archiving 7 6 Audit, monitoring and review 7 7 Associated documents 8 Appendix A Complaints Report Template 9 Appendix B Incidents Report Template 13 Appendix C Equality Impact Assessment Form 15 Appendix D Human Rights Act assessment Checklist 16 1 Introduction Successful risk management is underpinned through the development of a proactive culture whereby effective incident reporting, investigation and learning from incidents takes place that reduces the likelihood of incidents reoccurring. This reporting culture contributes to improved service user safety and service provision and makes the Trust a safer place to work and visit for staff, service users and the public. The Trust is committed to providing an environment and culture which minimises risk and promotes the health, safety and wellbeing of all those who use its services and enter or use its premises, whether as service uses, staff or visitors. The analysis of incidents, complaints and claims data follows on from the Trust s Incident Management Policy and the Investigation Policy. 2 Purpose of the Policy Policy for the Analysis and Improvement following incidents, claims and complaints Page 2 of 16

This policy has been developed to assist the organisation in combining and analysing the data gathered from incidents, complaints, and claims, including root cause analysis, to learn lessons, and make changes to improve practice. 3 Duties The Board The Board is responsible for: Ensuring robust incident, complaints and claims reporting, investigation and management systems are in place, that these are monitored and reviewed and compliant with external regulation; The monitoring and review of serious complaints, claims and incidents, ensuring that lessons are learnt and recommendations/actions implemented; The review of data from incident, complaints and claims reports to identify themes and trends, and ensuring appropriate action is taken. Quality Assurance Committee The Quality Assurance Committee is responsible for overseeing that robust incident, complaints and claims management processes are in place. The Committee is also responsible for receiving assurance from the that analysis of such data is carried out and any identified themes or trends are acted upon and improvements notified. The is responsible for ensuring that the incidents, complaints and claims data is monitored, collated, analysed and lessons learned are shared across the organisation. Policy for the Analysis and Improvement following incidents, claims and complaints Page 3 of 16

Executive Directors Executive Directors are responsible for taking necessary action when any themes or trends are highlighted as a result of the work that the does and for ensuring that this policy is implemented across the Trust. Complaints & Litigation Lead The Complaints and Litigation Lead is responsible for: monitoring and reporting on trends in respect of complaints and claims, e.g. number, issues, timeliness of complaints handling, outcome, lessons learned; providing a quarterly report which includes qualitative and quantative data to the Quality Assurance Committee; formulating and presenting staff training programmes on complaints and claims; undertaking an annual review of the complaints and claims processes; Risk Management Department The Risk Management Department will provide directorates and appropriate groups with information and data in respect of incidents to enable the collation and analysis to be undertaken. 4 Specific Details 4.1 Analysis of Incidents, Complaints and Claims All SHSC s incidents, complaints and claims are recorded on the Safeguard Risk Management System. This enables data to be retrieved quickly, easily and consitently. It enables the Trust to search for types of incidents, for example, as well as looking at a particular team to see their performance across the range of risk management issues. Incident, complaint and claims data, including investigation findings, resulting actions, lessons learned etc are reported through quarterly reports which are presented to Quality Assurance Committee. Monthly incident data is also reported to the and the Executive Directors. The reports provided offer historical data to enable comparisons and analysis over time to take place. Lessons learned are recorded on the Safeguard system to enable the analysis of incidents and ensure that improvements in practice occur as a result. 4.2 Combined Data Analysis Whilst the Trust reports on incidents, claims and complaints separately, all data of this nature is discussed at the. This ensure the group have the overview of any particular issues that may be ongoing, eg an increased incidence of complaints and incidents at ths same community team. Where patterns like this are apparent, the will seek further information on the reasons behind the increased occurrence of events from the relevant clinical and service directors in order to provide assurance to the Quality Assurance Committee that any highlighted issues have been, or are being addressed. Where further action is necessary, an action plan will be requested and monitored. Policy for the Analysis and Improvement following incidents, claims and complaints Page 4 of 16

Quantative data on complaints is available on Inform, the Trust s electronic website. It is a single repository of all the Trust s key performance indicators and data with the added intelligence of drill down into directorates, teams, dates, locations and many other options. The system allows analysis across all of the Trust operational systems to discover trends, inform decisions and understand service design. Trends and learning issues arising from complaints are included in the quarterly reports submitted to the Directorate Senior Management Team meetings. Action plans arising from complaint investigations are also reviewed and monitored on a quarterly basis at these meetings. 4.3 Sharing of Information, Learning and Improvement The sharing of the lessons learned post investigation is a critical part of incident management. Learning from service user safety incidents is a collaborative, decentralised and reflective process that draws on experience, knowledge and evidence from a variety of sources. The learning process is a process of change evidenced by demonstrable, measurable and sustainable change in knowledge, skills, behaviour and attitude. Learning can be demonstrated at organisational level by changes and improvements in process, policy, systems and procedures relating to service user safety. Individual learning can be demonstrated by changes and improvements in behaviour, beliefs, attitudes and knowledge of staff at the front line. What Constitutes Learning Learning following an incident should be linked to safety related policy, practice and process issues raised by the incident. Examples of learning are given below: solutions to address incident root causes which may be relevant to other teams, services and provider organisations; identification of the components of good practice which reduced the potential impact of the incident, and how they were developed and supported; systems and processes that allowed early detection or intervention which reduced the potential impact of the incident; lessons from conducting the investigation which may improve the management of investigations in future; documentation of identification of the risks, the extent to which the risks have been reduced, identified and how this is measured and monitored. 4.4 Disseminating Learning Learning from serious events is disseminated through various means in the Trust. The, which has representatives from across the Trust, discusses all actions arising from serious incidents at each meeting (taking one directorate at a time). This enables the directorate representatives to take the actions and learning from all serious incidents back into their directorates to share with their teams and learn from others experiences. Monthly reports on ongoing serious incidents are produced by the Risk Management Department and disseminated across the Trust. This enables directorates, where the incidents did not occur, to understand the type of incidents that have occurred elsewhere, so they can take proactive, preventative action, where necessary, to avoid recurrence in their areas of responsibility. Learning from executive level events is shared with the Board, through the reporting of the executive summary and action plan. Policy for the Analysis and Improvement following incidents, claims and complaints Page 5 of 16

Quarterly reports are produced by the Risk Management Department and Complaints and Litigation Lead which provide an analysis of all incidents, complaints and claims reported across the Trust. Serious events are recorded within these reports in greater detail and all root causes and lessons learned from them are included. These reports are presented to the Quality Assurance Committee, a Board sub-committee, as well as being published on the Trust s intranet site for all staff to access. A quarterly lessons learned bulletin is sent to all staff and published on the Trust s intranet. Teams/wards also discuss incidents, complaints and claims at their regular team governance meetings, in order to feedback findings, heighten understanding and share the learning. 4.5 Wider Sharing of Lessons Investigations may identify issues of national significance or where the dissemination of national learning is appropriate. user safety incidents are reported to the NPSA through the NRLS. When updates to the incidents are recorded on the Safeguard system, updates are sent to the NPSA. When an incident is closed, the root causes and lessons learned are inputted onto Safeguard, which then shares the findings with the NPSA and the Care Quality Commission. As the report and action plan is shared with relevant external stakeholders, this enables learning to be shared across organisational boundaries. Where the NHS rth of England perceives that lessons learned in one Trust may be relevant to others, this will be communicated through them and assurances sought from individual Trust Boards that necessary measures are either already in place or are being taken to prevent recurrence in their Trust. 4.6 Process for Implementing Risk Reduction Measures Where data analysis suggests that improvements are necessary to reduce potential risks and the likelihood of an event occurring, and action plan will be developed by the relevant service/team, in conjunction with the appropriate clinical and service director. These action plans will be presented to the, in order that assurance is provided to the Quality Assurance Committee. The implementation of action plans is the responsibility of the directorate which the issue relates to. Sometimes another directorate may have to do something to enable the other directorate to resolve the issue, eg an incident occurs on an acute ward, that requires an IT solution to solve the problem. The will oversee the implementation of actions, which as a result will reduce the level of risk in that area. Where risks are identified, these will be captured and recorded on the relevant risk register. The Trust s Risk Management Strategy provides further detail on the risk register process and the monitor of such risks. Where major risk issues are identified, these will be brought to the attention of the Executive Directors, who will oversee the development and implementation of any resulting actions surrounding this. Policy for the Analysis and Improvement following incidents, claims and complaints Page 6 of 16

5 Dissemination, Storage and Archive This policy will be disseminated to all staff via email following ratification. The policy will be stored on the Trust s intranet. 6 Audit, Monitoring and Review NHSLA Risk Management Standard 2.6- Monitoring Compliance Template Minimum Requirement Process for Monitoring Responsibl e Individual/ group/ committee A) Duties Appraisal Line manager Frequency of Monitoring Annual Review of Results process (e.g. who does this?) Line Manager Responsible Individual/grou p/ committee for action plan development Line Manager/ Appraisee Responsi ble Individual/ group/ committe e for action plan monitorin g and implemen tation Line Manager/ Appraisee B) How incidents, complaints and claims are analysed Report Quarterly Clinical and service directors C) How information is combined Report Quarterly Clinical and service directors D) Report template E) Sharing information Report Audit Head of Integrated Governance F) Action plans Audit Head of Integrated Governance G) Timescales Review Head of Integrated Governance Quarterly Biannually Quarterly Quarterly Clinical and service directors Head of Integrated Governance Clinical and service directors Head of Integrated Governance Policy for the Analysis and Improvement following incidents, claims and complaints Page 7 of 16

7 Associated Documents Risk Management Strategy Complints Policy Claims Management Policy Incident Management and Reporting Policy Policy for the Analysis and Improvement following incidents, claims and complaints Page 8 of 16

8 Appendix A Complaints Report Template Report to: Date: Subject: From: Prepared by: SUMMARY REPORT Quality Assurance Committee (insert date) Complaints Annual Report Wendy Hedland Complaints & Litigation Lead Wendy Hedland Complaints & Litigation Lead QAC (insert date) Item?? 1. Purpose This paper aims to provide the Quality Assurance Committee with a summary of the Complaints Annual Report (insert date). 2. Summary Current Year Previous Year Total number of formal complaints received Total number of oral or Fastrack complaints received Total number of compliments received Formal complaints responded to within agreed timescale Highest number of formal complaints by category Highest number of formal complaints by staff group Highest number of formal complaints by post code Highest number of formal complaints by age Highest number of formal complaints by gender Highest number of compliments received by Directorate Highest number of compliments received by Site The (insert date) response time of (insert percentage) can be benchmarked against the national average of 73% and Yorkshire and the Humber overall response rate of 70%. Policy for the Analysis and Improvement following incidents, claims and complaints Page 9 of 16

All complaints are reviewed to identify any themes or trends. (insert information on identified trends in current year) Where appropriate, action plans, including timescales for completion, are compiled by the Complaints & Litigation Lead and these are approved by the Chief Executive when he signs off each formal complaint response. The action plan is monitored on a weekly basis via the complaints monitoring system which is issued to all and Clinical Directors, investigating officers and business planning managers. The system is designed to ensure that necessary lessons are learned and changes implemented. On completion of the action plan, appropriate evidence is filed on the complaints master file to evidence a closing of the loop. Reviews indicate that the system is working well and has been commended by the Health Ombudsman. Action plans relating to complaints where recommendations have been made can be found on pages (insert page numbers) of the full report. (insert number) formal complaints were referred to the Health Ombudsman for Independent Review. (insert information relating to current status of complaints) Full details relating to all cases referred to the Ombudsman in (insert year) can be found on pages (insert numbers) of the full report. Benchmarking against other Mental Health Trusts in Yorkshire and the Humber Strategic Health Authority The Department of Health has yet to publish complaints data for (insert year). The Department no longer reports on response rates. For information, I am sharing below data in relation to (insert year): Mental Health Trusts in Yorkshire and the Humber South West Yorkshire Partnership NHS Foundation Trust Leeds Partnership NHS Foundation Trust Humber NHS Foundation Trust Sheffield Health and Social Care NHS Foundation Trust Rotherham Doncaster and South Humberside Mental Health NHS Sheffield Sheffield PCT Sheffield Teaching Hospitals NHS Foundation Trust Sheffield Health and Social Care NHS Foundation Trust Sheffield Childrens Hospital NHS Foundation Trust Formal Complaints Formal Complaints 3. Next Steps There are no next steps required. 4. Required Actions As all action plans arising from (insert year) complaints have been completed or are being actively monitored for completion; no further action is required. 5. Monitoring Arrangements The Complaints & Litigation Lead will continue to monitor response deadlines, themes/trends and the implementation and completion of action plans on a weekly basis and will submit quarterly reports to the Quality Assurance Committee. Policy for the Analysis and Improvement following incidents, claims and complaints Page 10 of 16

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6. Contact Details For further information, please contact: Wendy Hedland Complaints & Litigation Lead 0114 2718956 wendy.hedland@shsc.nhs.uk Policy for the Analysis and Improvement following incidents, claims and complaints Page 12 of 16

Appendix B Incidents Report Template Trust-wide Incident Management Performance Report Period 1 st October 2012 31 st December 2012 (Quarter 3 2012/13) Risk Management Department Policy for the Analysis and Improvement following incidents, claims and complaints Page 13 of 16

Contents Page. Introduction 6 Methodology 6 Report Distribution 6 Key to Colour Coding 6 1. Never Events 7 2. Serious Incidents 7 2.1 Breakdown of Serious Incidents by /Directorate 8 2.2 Analysis of Serious Incidents by Cause 8 2.3 Serious Incident Performance Data 9 2.4 Quality Grading of Reports 10 3. Safeguarding Incidents 10 4. Unexpected Deaths Reportable to HM Coroner 11 5. Suspected Homicides 11 6. Other Incidents Reported 12 6.1 Graphical Analysis by Directorate Q1 2012/13 and trend against previous quarter 14 7. Feedback/Themes & Lessons learned 17 8. National Reporting Learning Benchmarking Data 17 9. CAS Alert Responses/Action 18 Appendix 1 Q1 breakdown of Exploitation/Abuse Incidents 19 Appendix 2 Outcomes/Lessons Learned from Serious Incidents (Level 2 Investigations) occurring in Q1 2012/13 23 Policy for the Analysis and Improvement following incidents, claims and complaints Page 14 of 16

Appendix C Equality Impact Assessment Form To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Yes/ Comments Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? n/a n/a 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? n/a n/a If you have identified a potential discriminatory impact of this procedural document, please refer it to Liz Johnson (Head of Patient Experience Inclusion) together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Liz Johnson (Head of Patient Experience Inclusion and Diversity) Policy for the Analysis and Improvement following incidents, claims and complaints Page 15 of 16

Appendix D Human Rights Act assessment checklist 1 1.1 What is the policy/decision title? Insert here 1.2 What is the objective of the policy/decision? 1.3 Who will be affected by the policy/decision? 2.1 Will the policy/decision engage anyone s Convention rights? 2.2 3.1 YES Will the policy/decision result in the restriction of a right? YES Is the right an absolute right? NO NO YES Flowchart exit There is no need to continue with this checklist. However o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o o Legal advice may still be necessary if in any doubt, contact your lawyer Things may change, and you may need to reassess the situation 3.2 NO 4 The right is a qualified right Is the right a limited right? 3.3 YES Will the right be limited only to the extent set out in the relevant Article of the Convention? YES NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? NO Policy/decision is likely to be human rights compliant Policy/decision is not likely to be human rights compliant BUT Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. And you should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right Policy for the Analysis and Improvement following incidents, claims and complaints Page 16 of 16