ROTHERHAM GENERAL HOSPITALS NHS TRUST by PleK2y7b

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									                      OPEN BOARD OF DIRECTORS’ MEETING                             Open BoD: 26.01.11
                                                                                   Item:     7
                               26 January 2011


TITLE OF PAPER        Effective Management of Incidents and Serious Untoward Incidents (SUIs)
                      Up-date on Review of Incident Management Procedures


TO BE PRESENTED BY    Liz Lightbown, Executive Director of Nursing and Quality


ACTION REQUIRED       Board is asked to receive this briefing paper for information and awareness



OUTCOME               Following implementation of the Trust’s revised incident management policy
                      and procedures, it is expected that the number of incidents resulting in
                      harm will reduce, due to more efficient learning from incidents


TIMETABLE FOR         Discussion on revised procedures at January’s Board meeting
DECISION
                      Revised policy and procedures will be discussed at the Strategic
                      Leadership Group (SLG) in February and be presented to the Executive
                      Directors’ Group in February/March


LINKS TO OTHER KEY    NHSLA Risk Management Standards 2010/11
REPORTS / DECISIONS   CQC Essential Standards of Quality and Safety, March 2010
                      Internal Audit Report on Incident Management 2010


LINKS TO OTHER        Any risks outlined in Internal Audit reports are recorded on the Trust’s risk
RELEVANT              register
FRAMEWORKS            Any risks highlighted through incidents are recorded on local / Directorate
BAF, RISK,            Trust risk registers
OUTCOMES ETC


IMPLICATIONS FOR      Reduction in the number of incidents classified internally as ‘serious’, ie
SERVICE DELIVERY      current ‘moderate’ incidents should reduce the number of management
AND FINANCIAL         reports Directorates have to produce, thereby allowing more time to spend
IMPACT                investigating more serious incidents.


CONSIDERATION OF      Robust incident management systems and processes ensure a safer
LEGAL ISSUES          organisation, thereby reducing the number of litigation claims resulting from
                      incidents.
                      Non-achievement of NHSLA Risk Management Standards at level 1 will
                      result in loss of 10% discount on Trust’s contributions.


Author of Report      Tania Baxter
Designation           Head of Integrated Governance
Date of Report        January 2011
          Board Briefing on Review of Incident Management Procedures
                                 January 2011
1.        Background

SHSC is committed to providing an environment and culture that minimises risk and
promotes the health, safety and wellbeing of all those who utilise its services, and enter or
use its premises whether as service users, staff or visitors.

Incident management is an integral part of robust risk management and is included in both
the NHS Litigation Authority’s (NHSLA’s) Risk Management Standards and the Care
Quality Commission’s Essential Standards of Quality and Safety. Incident management
enables organisations to learn from incidents and control risks and is key to the
maintenance of patient and staff safety.

SHSC has around 6000 incidents and near misses reported every year. This means 6000
opportunities to improve our systems and practices. Of these reported incidents,
approximately 50 are ‘serious incidents’ externally reported both through NHS Sheffield
onto the Strategic Health Authority and through the National Patient Safety Agency
(NPSA) onto the Care Quality Commission (CQC).

Using the Trust’s current risk rating matrix, just under 400 incidents in 2010 were classified
as ‘moderate’ or above and rated as ‘amber’, thus requiring a detailed management report.
Under the revised risk rating matrix, the number of ‘orange’ or ‘red’ incidents would be
reduced to approximately 50.

It is anticipated that by improving our incident management procedures, the number of
actual serious incidents the Trust has is reduced, through faster and more effective
learning and system improvements following an incident.


2.    Effective Incident Management Procedures

In order to become more effective at learning from incidents, thereby reducing the number
of incidents that result in harm occurring, the Trust has reviewed the current system and
has identified clear recommendations for improvement to its incident management
processes and systems. These include:

           Revising the Incident Management Policy and Procedures;
           Introducing new electronic incident reporting forms (IR1 and IR2);
           Introducing a revised risk rating matrix, based upon the National Patient Safety
            Agency (NSPA) guidance;
           Increasing the threshold whereby detailed investigation reports are required,
            enabling more local learning from low risk incidents;
           Encouraging more effective methods of sharing learning from incidents within
            directorates and improving the reporting of performance and learning across the
            organisation;
           Clarifying roles and responsibilities at each stage of the incident management
            process.




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3.     Changes to Incident Management Policy and Procedures

The new policy provides more guidance for staff on the actions to take immediately on the
occurrence of an incident. It also clearly defines the roles and responsibilities that staff,
managers, teams and directorates have in positively managing the incidents that occur
within their services. New guidance is provided on how to assess the seriousness of an
incident and the action that needs to be taken which is dependant upon the relative risk
grading of the incident, as described below.

Immediate Incident Response

As with any incident, immediate actions are required to be taken by individuals in order to
ensure service user and staff safety is maintained at all times. This may involve providing
first aid, securing an area, removing defective equipment (whilst keeping it in-tact), liaising
with and supporting family members, etc. Corrective action must be taken to ensure
service users, staff, members of the public and the environment are safe.

Incident Reporting

All incidents will be recorded using a standardised electronic IR1 form. This form will
guide staff through the process of recording key facts and grading the incident, to inform
the level of incident and onward actions. The forms will be accessed through the intranet
and could be held locally (electronically) for convenience. The Trust hopes to introduce a
link to the incident reporting forms directly from Insight (our Patient Administration
System). Once completed, the IR1 forms are sent electronically to the Risk Management
Department. Dependant upon the grading of the incident (see below), determines whether
only an IR2 form (incident investigation record) is required from the service reporting the
incident, or whether a more detailed investigation is required. It will be the responsibility of
the local team manger to grade all reported incidents as soon as possible following the
incident to determine what level investigation is required and initiate the next stage of the
incident management process.

Risk Grading and Actions Required

Revised Risk Rating Matrix

Below is the risk rating matrix currently used by the National Patient Safety Agency
(NPSA). SHSC will adopt this matrix across the organisation for all its risk management
functions.

                                                             Likelihood
     Consequence              Rare           Unlikely         Possible       Likely         Almost
                               (1)             (2)              (3)           (4)           certain
                                                                          (please include     (5)
                                                                            unexpected
                                                                           deaths in this
                                                                             category)
     Negligible     (1)         1                2                   3          4             5
     Minor          (2)         2                4                   6          8             10
     Moderate       (3)         3                6                   9         12             15
     Major          (4)         4                8               12             6             20
     Catastrophic   (5)         5               10               15            20             25




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Negligible or Minor Risk (Green Rated)

Incidents rated as ‘green’, using the risk matrix, should be reported using the incident
reporting form (IR1) and forwarded to the Risk Management Department as soon as
possible, and within 3 working days of the incident. They should be investigated within the
department/service within 4 days of occurrence and an incident investigation record (IR2)
completed which will outline any actions taken and lessons learned. Any information given
to service users, carers/family, staff and/or members of the public must be recorded. The
completed IR2 must be sent, preferably electronically, to the Risk Management
Department within a maximum of 10 working days of the incident. A post incident
debriefing, counselling and support will be arranged by the Ward/Department Manager as
appropriate for patient, carers, visitors and staff team.

For all negligible or minor incidents (green rated), staff feedback, dissemination of lessons
learned and any following up of action plans will be the responsibility of the team/ward
manager using their Team Governance and local risk register processes. Monitoring of
incidents will be undertaken through directorate reviews of team governance reports and
local risk registers.

The information from the incident report forms (IR1 and IR2) will be entered onto the
Trust’s Safeguard system by the Risk Management Department and used to inform
teams/directorates/the Trust of any trend analysis, recurring themes, etc. All incidents will
also be reported to the appropriate external agencies as appropriate by the Risk
Management Department.

Moderate Risk (Yellow Rated)

Incidents rated as ‘yellow’, using the risk matrix, must be escalated to directorate leads by
the ward/area manager within 24 hours of the incident occurring, or to the on-call duty
manager if out of hours. As previously an IR1 form must be completed as soon as
possible and forwarded to the Risk Management Department. A concise investigation
(level 1 investigation), must be carried out within 4 days of the incident and recorded using
the IR2 form. Such incidents must be proactively managed and monitored by area
managers/middle managers and recorded on local risk registers, where appropriate.
Moderate incidents must be fed into directorate governance processes for action and
monitoring of action plans and dissemination of learning. Any immediate lessons learned
must be shared. Any information given to service users, carers/family, staff and/or
members of the public must be recorded. A completed IR2 form must be sent, preferably
electronically to the Risk Management Department within 7 working days of the incident
occurring. A post incident debriefing, counselling and support will be arranged by the
Ward/Department Manager and the Operational Leads as appropriate for service users,
carers, visitors and staff team following the Trust’s Being Open and Supporting Staff
policies.

For all moderate incidents (yellow rated), staff feedback, dissemination of lessons learned
and any monitoring and management/following up of action plans will be the responsibility
of the directorate(s) area/ward managers using their directorate governance and risk
register processes.

As outlined previously, information from the incident report forms (IR1 and IR2) will be
entered onto the Trust’s Safeguard system by the Risk Management Department and used
to inform directorates/the Trust of any trend analysis, recurring themes, etc. All incidents
will also be reported to the appropriate external agencies as appropriate by the Risk
Management Department.
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Major/Catastrophic Risk (Orange or Red Rated)

Incidents rated as ‘orange’ or ‘red’ must be immediately escalated to the relevant clinical
and service directors by the ward/area manager, or to the on-call duty manager if out of
hours. An incident form (IR1) must be completed stating any immediate actions
taken/outcomes. This should be immediately emailed to risk.risk@shsc.nhs.uk or faxed
immediately to the Risk Management Department. An initial interim report must be
completed by the area/ward manager within 24 hours of the incident occurring and
submitted to the clinical and service directors and the Risk Management Department.

For all major/catastrophic incidents (orange or red rated) an internal investigation (level 2
investigation) is required. An Executive Director will be nominated to lead the investigation
team. The Executive Director will call a meeting of key senior people and a panel will be
brought together within 48 hours of the incident occurring and Terms of Reference for the
investigation set. At the meeting, a communications plan for the service users and families
affected, for staff and, if appropriate, the media, will be agreed. The meeting will be co-
ordinated through the Risk Management Department. Where possible, investigators will
not be known to the area where the incident occurred to ensure a level of neutrality.
Investigating officers will be supported by an appropriate Risk Management
Lead/Investigation Lead for the Trust who is trained to an advanced level in Root Cause
Analysis (RCA). The investigation team will include a member of Human Resources to
ensure a fair and reasonable approach to the investigation is undertaken. This may not
be necessary in all cases and each case should be considered individually after discussion
with the Director of HR and/or Senior HR Officer. Any staff interviews will be recorded
using a ‘Record of Events’ proforma which will be signed by both the interviewee and
interviewers and forms part of the investigation process/evidence.

For all major/catastrophic incidents, an internal investigation report must be completed by
the Lead Investigator and sent to the Risk Management Department for quality assurance
purposes. Once the report is quality checked, it will be sent to the relevant directors of the
directorate the incident occurred in to formulate an action plan, based upon the
recommendations made within the report. The fully completed and directorate approved
internal investigation report must be submitted to the Risk Management Department within
8 weeks of the incident occurring. All completed internal investigation reports will be
reviewed by a new working group for rigorous quality assurance and validation of
recommendations, actions and lessons to be learned. On completion of this validation
process, the internal investigation report will be presented to the Executive Directors
Group for final approval. Where the incident has been externally reported, the Risk
Management Department will ensure the approved reports are forwarded to the relevant
external agencies.

For all major or catastrophic incidents (orange or red rated), staff feedback, dissemination
of lessons learned and any monitoring and management/following up of action plans will
be undertaken through the new governance structure, including assurance through the
new Board Sub Committee - Quality of Care Committee (QCC). Any risks associated with
these incidents will be recorded either on a risk register at directorate or Trust level, or the
Board Assurance Framework (BAF), dependent upon the severity of the issue.

The Board will receive regular assurance on all major and catastrophic incidents together
with exception reports on performance where this is necessary and appropriate, through
its governing committee structure.




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External Reporting

The Trust is required to report incidents of a certain nature to various external agencies
and stakeholders. Which incidents are reported to whom depends on the type of incident,
the service(s) involved, the seriousness of the incident and a variety of other criterion.

The Trust is currently performance managed on its serious incidents by NHS Sheffield.

A serious incident requiring investigation is defined by the NPSA in the National
Framework for Reporting and Learning from Serious Incidents Requiring Investigation as
an incident that occurred in relation to NHS-funded services and care resulting in one of
the following:

         Unexpected or avoidable death of one or more patients, staff, visitors or members
          of the public;
         Serious harm to one or more patients, staff, visitors or members of the public or
          where the outcome requires life-threatening intervention, major surgical/medical
          intervention, permanent harm or will shorten life expectancy or result in prolonged
          pain or psychological harm (the includes incidents graded under the NPSA
          definition of severe harm);
         A scenario that prevents or threatens to prevent a provider organisation’s ability to
          continue to deliver health care services, for example, actual or potential loss of
          personal/organisational information, damage to property, reputation or the
          environment, or IT failure;
         Allegations of abuse;
         Adverse media coverage or public concern about the organisation or the wider
          NHS;
         The occurrence of a ‘Never event’. (A never event is described as a serious, largely
          preventable patient safety incident that should not occur if the available preventative
          measures have been implemented by healthcare providers).

All serious incidents, reported to NHS Sheffield, require a thorough and detailed internal
investigation (level 2 investigation). All reports, together with approved action plans, must
be authorised by the Executive Directors Group and submitted to NHS Sheffield within 12
weeks of the incident occurring.

4.        Current Position

        The Trust’s incident management policy has been revised and is currently being
         consulted upon;

        The Trust’s IT systems are being assessed with regards to the electronic incident
         reporting forms;

        Options regarding full electronic incident reporting are being explored with Ulysses
         (the provider of the current Safeguard risk management system);

        The revised risk rating matrix has been tested using the incidents reported to the
         Trust in 2010. These figures show a reduction in currently classified ‘serious
         incidents (ie those currently rated as ‘amber’) from over 350 to under 50. These
         incidents were also subject to over 180 management reports being requested. Using
         the new matrix, this figure should reduce to less than 25.


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5.    Next Steps

     Finalise the incident management policy, including the revised risk rating matrix,
      review policy against revised SHA guidance on serious incident management
      processes and arrange its full implementation (including associated training) from
      1 April 2011;

     Strengthen performance reporting and learning from incidents within team, directorate
      and the Trust’s governance arrangements and governing committees structure;

     Finalise the appraisal of full electronic (web-based) incident reporting system;

     Audit the outcomes following implementation of the revised policy to ensure that the
      desired improvements are realised. It is suggested that this takes place at least 6
      months post implementation of the new policy and is undertaken by Internal/External
      Auditors;

     Performance manage the incident management processes, including completion of
      actions, through the new Board Sub Committee - the Quality of Care Committee
      (QCC), ensuring that this provides the necessary and appropriate assurances for the
      Board;

     Finalise the Trust’s new governance arrangements for quality and patient safety and
      ensure incidents are included in the remit of the appropriate groups for assurance,
      monitoring, learning and the dissemination of learning throughout the Trust.


Tania Baxter
Head of Integrated Governance
14 January 2011


For more information on incident management procedures, or if you have any queries,
please contact:

Tania Baxter, Head of Integrated Governance
Tel: 0114 2263279
tania.baxter@shsc.nhs.uk

Carol O’Neill, Clinical Risk Manager
Tel: 0114 2716371
carol.oneill@shsc.nhs.uk




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