Healthcare Improvement Scotland (HIS) Improvement Plan for the Review of Significant Adverse Events

Transcription

1 Healthcare Improvement Scotland (HIS) Improvement Plan for the Review of Significant Adverse Events This document sets out the actions that NHS Ayrshire and Arran will complete to give assurance to the public of its commitment to continuous improvement in the management of Significant Adverse Events.. The following sections of this report outlined the Recommendations made by Healthcare Improvement Scotland, followed by details of the Improvement Actions that were identified, the progress that has been made in implementation Recommendation 1 Strengthen the process NHS Ayrshire & Arran must strengthen its current Adverse Event Policy to make sure it adheres to the National Framework and provides useful and practical processes that can be quickly and simply followed. Detailed Recommendation (1a) Include clinical engagement in reviews, completion of documentation, the level of review and analysis based on adverse event category, and the improvement planning and monitoring arrangements for review. NHS Ayrshire & Arran Improvement Action 1. ate Adverse Event Review Groups (AERG) to establish formal terms of reference which will be consistent across NHS Ayrshire & Arran. 2. ate AERGs to ensure agreed Significant Adverse Event SBAR is completed for decision making for review level of all category I and consequence score 4/5 adverse events for scrutiny at the AERG and attached to the electronic record Completion Date Due Lead officer Progress Evidence 31 st August Assistant See Theme 2: Adverse Event 18, 19, 20, for Occupational 21, 22 Health, Safety and Risk 30 th September Assistant for Occupational Health, Safety and Risk See Theme 2: Adverse Event 22 Page 1 of 14

2 (Datix). 3. Fortnightly report to Medical and Nurse of status of all SAE Reviews. Fortnightly meetings will be held with Medical, Nurse, and Nursing to review all SAE. 4. Six monthly reports to be submitted by each ate AERG to the Healthcare Committee 31 st August Medical and Nurse 28 th February 2018 Associate Nurse s and Medical s See Theme 2: Adverse Event See Theme 2: Adverse Event (1b) Taking advice from other NHS Scotland Boards to find practical ways of implementation. 1. NHS Ayrshire & Arran will undertake review of existing policy against Healthcare Improvement Scotland Framework. 31 st July Assistant for Occupational Health, Safety and Risk Adverse Event Policy 7 Page 2 of 14

3 2. NHS Ayrshire & Arran will seek academic/best practice review of effective management of adverse events for inclusion and consideration of review of the of Adverse Events Policy. 3. NHS Ayrshire & Arran will commission an external auditor to review compliance of existing policy against HIS Framework. 30 th September Assistant for Occupational Health, Safety and Risk Adverse Event Policy 30 th October Medical Adverse Event Policy 8 9 (1c) Involving clinicians from across the organisation, including maternity services, in its (Policy) development. 1. Stakeholder engagement and consultation programme on revised policy, processes and supporting resources. 30th September Assistant for Occupational Health, Safety and Risk Adverse Event Policy 10, 11, 12, 13, 14, 15 (1d) The revised adverse event management policy must provide information for families about stillbirth, neonatal death and adverse events that communicates 1. Take into consideration the national work carried out by the Maternity Clinical s Group to identify a consistent approach to the review process for stillbirth and neonatal death. 31 st December Assistant for Occupational Health, Safety and Risk Adverse Event Policy and; Theme 3: Families Page 3 of 14

4 accurate, clear and consistent messages about the type of review that is being undertaken. This should aim to avoid any additional distress by raising uncertainty about the type of review that may be conducted. 2. Review the Adverse Events Policy with a view to having a more refined process which will enable staff to consistently and reliably review adverse events. 3. Develop specific patient/service user, carers and family information literature which details the adverse events process and ensure this relates to guidance provided by SANDS. Assistant for Occupational Health, Safety and Risk Assistant Nurse Adverse Event Policy Adverse Event Policy and; Theme 3: Families 16 Page 4 of 14

5 Recommendation 2 Family Engagement NHS Ayrshire & Arran must make sure that families are provided with appropriate information, support and opportunities to enable them to be involved in any significant adverse event process, in line with the National Framework. Detailed Recommendation (2a) Reference to and implementation of the guidance from the Being Open NHS Scotland 2015 document. This document provides support for Boards in developing policy and procedures around communication and engagement. (2b) Opportunities for staff to have communication training to support Being Open. NHS Ayrshire & Arran Improvement Action 1. The revised Adverse Events Policy will include the principles from the Being Open NHS Scotland 2015 document. 2. Specific guidance on delivering an authentic apology that also meets the Duty of Candour legislation will be included within the revised Adverse Events Policy. 1. Awareness sessions to be developed and available to all staff which will incorporate Being Open and Duty of Candour. Completion Date Due Lead Officer Progress Evidence 31 st March 2018 and Assistant Nurse Adverse Event Policy Adverse Event Policy and Theme 5: Duty of Candour Adverse Event Policy and Theme 5: Duty of Candour 17, (2c) Further opportunities for those families that have come forward through this review process to discuss their experiences with NHS 1. Nurse and Medical will offer to meet with families at a time and venue of their convenience to ensure that any remaining questions 31 st July Nurse and Medical See Theme 3: Families 16 Page 5 of 14

6 Ayrshire & Arran, and to make sure that any remaining questions are answered. are answered. Page 6 of 14

7 Recommendation 3 Support for staff - NHS Ayrshire & Arran staff must be adequately supported to be involved in the management of adverse events across maternity services. Detailed Recommendation (3a) Dedicated and protected time for staff to be involved in all aspects of adverse event reviews. NHS Ayrshire & Arran Improvement Action 1. Increase capacity to undertake adverse event reviews which will include bespoke investigation and root cause analysis training. Completion Date Due (preparation of material) 31 st August 2018 (training delivery complete) Lead Officer Progress Evidence 2. Incorporate the requirement to be involved in the management of adverse events in the job planning process for medical staff (to also include dedicated time for adverse event reviews). 3. Recruitment of a dedicated Maternity Clinical Risk post for Women, Children and Diagnostic Services as part of the Maternity Services Risk and QI Team. 4. As part of the delivery of the Risk 31 st March 2018 Associate Medical s 31 st August Associate Nurse for Women and Children s Services Phase 1: 30 th December Medical, Nurse and See Theme 6: Maternity Workforce See Theme 6: Maternity Workforce See Theme 6: Maternity Workforce 41, 42 36, 37, 38, 39 Page 7 of 14

8 (3b) Appropriate support to undertake the review process including coordination and administrative support. (3c) Training in adverse event management review for those taking part in this process. Improvement Plan, Line Managers will include staff having dedicated and protected time for adverse event management in the setting of departmental objectives. These objectives are to be included in the service dashboard. 1. Review AMU support resources following consultation and agreement of Adverse Event Policy and provide necessary coordination and administrative support for all reviews. 1. Training to be developed, schedule prepared and delivered to those taking part in the process. (1 st Consultant post) Phase 2: 31 st March 2018 (2 nd consultant Post) Human Resource 30 th July Medical and Nurse 31 st August 2018 Assistant HR (Development) See Theme 6: Maternity Workforce 40 Page 8 of 14

9 Recommendation 4 Promote shared learning - NHS Ayrshire & Arran should promote internally and externally the changes and learning resulting from their improvement work, including the publication of learning summaries of adverse event reviews. Detailed Recommendation (4a) Learning summaries should be shared with staff, patients, families and carers and published on the Adverse Events Community of Practice website. (4b) The learning summaries should include a summary of what happened, the NHS Ayrshire & Arran Improvement Action 1. The development and management of learning summaries to be incorporated into the of Adverse Events Policy. 2. Review and update the governance process for the learning arising from adverse events (from point of care to Healthcare Committee). 3. Measure the effectiveness of the learning process. 1. Template for learning summaries to be reviewed and used as standard following Completion Date Due Lead Officer Progress Evidence and Assistant Nurse 31 st March 2018 and Assistant Nurse Assistant Nurse See Theme 2: Adverse Events See Theme 2: Adverse Events See Theme 2: Adverse Events. See Theme 2: Adverse Events 13, , 26 Page 9 of 14

10 learning gained, improvement work taken forward and resultant service improvements. completion of each review. (4c) The learning summaries should be considered as a mechanism for publishing examples of positive outcomes from improvement work taken forward following adverse event reviews to benefit services across NHS Scotland. 1. recommendation 4 (a) recommendation 4 (a) recommendation 4 (a) recommendation 4 (a) Page 10 of 14

11 Recommendation 5 Publication of reports - NHS Ayrshire & Arran should stop publishing redacted SAER reports on its website as these reports do not encourage shared learning and risk breaching patient/ family confidentiality. Detailed Recommendation (5a) NHS Ayrshire & Arran should stop publishing redacted SAER reports on its website as these reports do not encourage shared learning and risk breaching patient/ family confidentiality. NHS Ayrshire & Arran Improvement Action 1. NHS Ayrshire & Arran to stop publishing redacted SAER reports and remove existing reports previously published Completion Date Due 30 th September Lead Officer Progress Evidence Assistant Nurse See Theme 2: Adverse Events 25 Page 11 of 14

12 Recommendation 6 Staff Training and Education - NHS Ayrshire & Arran must make sure that that the training and development needs of staff are identified and met in a timely manner. Detailed Recommendation (6a) NHS Ayrshire & Arran should produce a training needs analysis. NHS Ayrshire & Arran Improvement Action 1. Scoping exercise for NHS Ayrshire & Arran to be carried out to identify training needs of those taking part in adverse event review. This exercise will include Root Cause Analysis and adverse event review/ investigation. Completion Date Due 28 th February 2018 Lead Officer Progress Evidence 3, 27, 29, 30, The AMU team will ensure the programme of training has capacity for all nursing/midwifery staff at AMU attend prompt training on an annual basis. 31 st October General Manager Women Children and Diagnostics Maternity Services to deliver a minimum of forty one hour face to face CTG training sessions per annum. All midwives interpreting CTG will 31 st March 2018 Associate Nurse / Associate Medical 32 Page 12 of 14

13 (6b) NHS Ayrshire & Arran should ensure access to training programmes. (6c) NHS Ayrshire & Arran should monitoring attendance at training. attend a minimum of two sessions per annum. 4. All midwives interpreting CTG to undertake K2 training. 1. Training sessions identified from training needs analysis to be cascaded throughout the organisation to ensure all staff have access to relevant training programmes. 1. Training records to be maintained and detail captured on organisations electronic system. 2. Training figures to be presented as part of the organisations performance report to the Risk Committee and as part of the s Assurance Reports to provide assurance that training is accessible and attended. 3. Women, Children and Diagnostic Services to develop a dashboard to monitor compliance of attendance at 31 st March 2018 Associate Nurse 31 st March st March st March 2018 and s 31 March 2018 General Manager Women Children and Diagnostics Page 13 of 14

14 training. Review of dashboard to be undertaken at every management team meeting. Page 14 of 14