Escalation Procedure. Purpose & definition

Transcription

1 Escalation Procedure Purpose & definition This document describes the procedure that the Healthcare Environment Inspectorate will follow to escalate issues or matters of evident concern arising from the inspection of NHS hospitals. This procedure should be read in conjunction with the HEI managing concerns procedure, the relevant memoranda of understanding (local Fires Authorities, the Health and Safety Executive (HSE) and the Mental Welfare Commission) and the procedure for follow up activity, set out in our inspection methodology. The HEI managing concerns procedure provides operational guidance for inspectors on how to manage and escalate any safeguarding issues identified by them or another person during inspection about the protection of children and vulnerable adults in healthcare settings. Stakeholders We work with a range of external stakeholders, including: Patients and the public including representative groups for the voluntary and independent sector Scottish Government Health Protection Scotland Health Facilities Scotland NHS boards NHS Education for Scotland (NES) Author: Lindsay Guthrie Page: 1 of 5 Review date: ongoing

2 Health and Safety Executive Mental Welfare Commission Care Inspectorate Scottish Local Authorities Aims of Informal and Formal Escalation The HEI can escalate matters of concern via both formal and informal routes. The severity of the issue arising will determine how and to whom the concern will be escalated to. In some circumstances, the HEI may pursue formal escalation of a serious issue without first engaging in informal escalation activity with the NHS board. The HEI will inform the NHS board on the day of inspection or as soon as possible of our concerns. This is to allow them to take immediate steps to address the issues, and protect the safety and welfare of patients, staff and the wider public. The aims of informal escalation are: to achieve resolution of the issue through dialogue and cooperation between the NHS board, HEI and external stakeholders as appropriate to maintain transparency and oversight of the process and to provide assurance for external stakeholders, and to promote public assurance through the timely reporting of inspection findings and improvement action plans. Formal escalation will occur when: legislation defines the appropriate action in response to the issue arising serious issues are identified which pose a threat to patient safety and public health, and there is a failure to take action to resolve issues. Author: Lindsay Guthrie Page: 2 of 5 Review date: ongoing

3 Definitions and levels of escalation Level 1 (Informal) - Concerns arising from inspection or engagement with the NHS board accountable officer and/or Executive Lead prior to publishing the report Action: Senior NHS board staff will be informed of the concern to allow them to take appropriate remedial steps if the issue arises during an inspection. Timescale: on the day of inspection. Action: The lead inspector will arrange to meet with senior NHS board staff to discuss and agree an improvement action plan Timescale: As soon as possible after the inspection and within 5 working days Action: The Chief Inspector will alert the HIS Chief Executive and Director of Scrutiny and Assurance who may arrange to discuss with the NHS board Chief Executive and/or Chair concerns arising from the inspection. Timescale: As soon as possible after the inspection and within 5 working days. Action: The Chief Inspector will inform the Scottish Government in order that policy leads are sighted on the issues of concern prior to publishing the inspection report. Timescale: prior to report publication date. Level 2 (Informal) Improvement action plans are inadequate or not developed or not progressed within the required timeframe. Action: The lead inspector will contact the NHS board to discuss the content and timescales for submission. Timescale: within 5 working days of receipt of action plan/timeframe limit Action: HEI may undertake further follow up inspection activity to assess progress with the improvement action plan Action: The Chief Inspector will alert the Healthcare Improvement Scotland Chief Executive and Director of Scrutiny and Assurance who may arrange to discuss with the NHS Board Chief Executive and/or Chair. Author: Lindsay Guthrie Page: 3 of 5 Review date: ongoing

4 Timescale: within 10 working days of receipt of the action plan or if no action plan is developed Action: The Chief Inspector will inform the Scottish Government policy lead of the issue Timescale: within 10 working days of receipt of the action plan/timeframe limit Level 3 (Formal) Serious issues (including health and safety) identified during inspection inspection activity Action: The lead inspector will inform Senior NHS board staff of the issue to allow them to take appropriate remedial steps to safeguard patient, staff and public safety. Timescale: on the day of inspection. Action: The Chief Inspector will inform the Scottish Government policy lead and Healthcare Improvement Scotland Chief Executive and Director of Scrutiny and Assurance. This may be followed up by a formal letter from the lead inspector or the Chief Inspector including supporting evidence, outlining requirements for action. Timescale: on the day of inspection. Letter will be sent within 5 working days. Action: The Chief Inspector will advise other agencies of the issue (eg Health & Safety Executive) as appropriate. Timescale: on the day of inspection or as early as possible thereafter Level 4 (Formal) Serious issues are not taken forward in a timely manner and in line with the agreed improvement action plans Follow-up activity Action: The Chief Inspector will formally advise the policy lead at the Scottish Government of the issue, supported by requirements for action. Action: The Scottish Government will determine appropriate action and follow up. Author: Lindsay Guthrie Page: 4 of 5 Review date: ongoing

5 LEVEL 3 FORMAL ESCALATION serious issue identified during inspection Safeguarding or matter of evident concern? LEVEL 1 INFORMAL ESCALATION concern arising from inspection or engagement with the NHS board prior to publishing the inspection report Progress Follow up activity (as per methodology) Inspection Outcome INSPECTION PROCESS (continuous) Action plan submitted Report published Outcome LEVEL 4 FORMAL ESCALATION serious issues are not taken forward in a timely manner and in line with the agreed improvement action plans Action plan LEVEL 2 INFORMAL ESCALATION Improvement action plans are inadequate or not produced or not progressed within the required timeframe LEVEL 1 INFORMAL ESCALATION concern arising from inspection or engagement with the NHS board prior to publishing the report Author: Lindsay Guthrie Page: 5 of 5 Review date: ongoing