Regional Mortality and Morbidity Review System Business Continuity Plan

Transcription

1 Regional Mortality and Morbidity Review System Business Continuity Plan Purpose of the Document This Business Continuity Plan (BCP) describes the process for ensuring business continuity in the event of inability to access the Northern Ireland Electronic Care Record (NIECR) system or part thereof, whenever a death is to be recorded or a mortality pathway amended. It provides guidance to staff to ensure essential clinical information can still be processed when NIECR is unavailable. Version 1.0 Status Final Date November 2017 Review Date November 2020 Clinical Guidelines ID: CG0504

2 1. Introduction Northern Ireland Electronic Care Record (NIECR) NIECR is a central repository of key information on patients/clients across Northern Ireland and contains key information from a number of feeder systems (Appendix 1). As with all IT systems, there are occasions (both planned and unplanned) when NIECR will not be available, such as upgrades and repairs of the system during local or regional network or server failures. It should be noted that the operational functionality of RM&MRS is highly dependent on the underlying NIECR functionality and its availability. Regional Mortality and Morbidity Review System (RM&MRS) The RM&MRS was developed to ensure that all deaths in HSC Hospitals are accurately recorded, reviewed, monitored and analysed. This will: provide a complete and legible Medical Certificate of Cause of Death (MCCD) that can be printed; provide additional scrutiny of deaths in hospital through peer review; enhance a culture of learning across trusts; improve reporting of serious adverse incidents where a death has occurred; and act as an additional safeguard to ensure that deaths are appropriately reported to the Coroner. The RM&MRS, through the Mortality pathway within NIECR, has been designed to ensure that all deaths in hospital are: Certified accurately by the attending doctor and/or appropriately reported to the Coroner; Reviewed by a Consultant; and Reviewed by multi-disciplinary teams at Specialty Mortality Review and Patient Safety meetings. In the event of an inability to access RM&MRS within NIECR, this BCP will provide the guidance to ensure essential clinical responsibilities can still be delivered. Regional Mortality and Morbidity Review System Business Continuity Plan Page 2 of 24

3 2. Aims and Objectives To identify the process to ensure business continuity is maintained in the event of an inability to access RM&MRS within NIECR. The scenarios include what to do when RM&MRS is unavailable and what to do when availability of the system is restored. 3. Duties and Responsibilities Death Certification Policy and Legislation Branch, DoH RM&MRS Implementation Facilitator and/or Trust equivalent Local ICT Service Desk Manager (Trust IT Helpdesk) BSO NIECR staff Overall policy responsibility for RM&MRS, its implementation and ensuring the BCP is reviewed and updated as appropriate. Responsible for ensuring that the BCP is put into place within the Trust and that it is reviewed regularly to ensure that it is meeting the requirements of the Trust. Responsible for ensuring that the local ICT service desk is aware of the continuity arrangements. Responsible for regional communications and resolution arrangements in respect of Infrastructure issues via the Service Desk Bulletin Board (Infra) and via to the ConsolidationLive distribution list. Responsible for regional communications and resolution arrangements in respect of NIECR via NIECR Implementation Managers. 4. Business Continuity Plan Scenarios Scenario 4.1 Unplanned Loss of Access to NIECR, affecting access to RM&MRS Unplanned loss of access to RM&MRS through NIECR can be caused by local/trust issues (e.g. local power failure, local network issues) or Regional Issues (e.g. issues with the regional NIECR infrastructure) i.e. cannot logon to NIECR. Actions In the event of unplanned loss of access to or slow-running of RM&MRS through NIECR, users should, Inform the local Trust IT service desk. Contact details for local Trust IT service desk Tel: or SHSCT intranet homepage: IT Support Intra Portal / Log a NIECR incident Regional Mortality and Morbidity Review System Business Continuity Plan Page 3 of 24

4 The next steps depend on what section of RM&MRS is inoperable. Initial Record of Death If advised that the loss of access will be short-term (a matter of hours) you may choose to wait until normal service is resumed. In the absence of access to RM&MRS through NIECR for a period which is going to be longer or is uncertain and/or where a MCCD is urgently required, staff will: Complete the MCCD manually using the MCCD book and/or complete the Coroner s Clinical Summary recorded onto the WORD version Template. (Appendix 2) Contact details for obtaining MCCD book Directorate Site Contact details Acute Children & Young People Mental Health & Learning Disability Older People & Primary Care Craigavon Area Hospital Daisy Hill Hospital Craigavon Area Hospital Daisy Hill Hospital Bluestone Gillis Ward Lurgan Hospital South Tyrone Hospital Bed/site Manager s office Bed/site Manager s office Bed Manager Nurse-in-charge Sister s office Sister s office, except for: Ward 1 MCCD booklet is in the doctor s office desk Advise the Mortuary verbally of MCCD completion. Contact details for Mortuary or /fax the required documentation to the Coroner s Office, see Appendix 3 for guidance on when to notify the Coroner of a death and further contact details. Regional Mortality and Morbidity Review System Business Continuity Plan Page 4 of 24

5 Contact details for Coroner s Office Telephone: Consultant Review Form When the RM&MRS is inaccessible, you will not be able to carry out a Consultant review. Patient M&M Review Generally, the list of deaths for review is not available when NIECR is not operational. It will therefore be difficult to progress through the M&M review aspect of a Specialty Mortality Review & Patient Safety meeting. Staff should, Defer the M&M review of deaths until the system access returns to normal. If necessary, urgent learning could be discussed, actions decided upon and recorded onto the WORD version of the M&M Review Template. (Appendix 4). Responsibilities The local Trust IT service desk will determine whether the issue is Local or Regional. For a Local connectivity issue, the responsibility lies with the local Trust IT support team, who will work to resolve the issue following standard Trust procedures and advise users accordingly. Where the issue is Regional, the local Trust IT support team will pass the call onto the Regional NIECR team by contacting the BSO Helpdesk on or by logging a request via Infra (SHSCT, SEHSCT or NHSCT) or by using the supportteam@hscni.net (BHSCT and WHSCT). The Regional team will work to resolve the issue within the agreed timeframes and will provide feedback to all local Trust IT support teams and NIECR Implementation Managers for dissemination to the affected users. Communication Resolution on System Restoration Where possible, Trust-wide IT communications will be sent by Trust to system users to inform them of the issue. Users will be notified when system access is restored via Trust wide communications and the notice board on the NIECR login screen. Initial Record of Death (IRD) Complete the IRD Form when the system access returns to normal, including entering the exact terms used on the handwritten MCCD. Regional Mortality and Morbidity Review System Business Continuity Plan Page 5 of 24

6 Enter the same details into the SBAR boxes of the IRD as used in the WORD Template of the Coroner s Clinical Summary. Both the MCCD and the Coroner s Clinical Summary will appear into the Clinical Document View once the IRD has been completed. Alternatively, a copy of the WORD version of the Coroner s Clinical Summary can be added to the patient record by following the Attach a Document guidance at Appendix 6. Consultant Review Form Complete the Consultant Review Form when the system access returns to normal. Patient M&M Review Update the M&M review when NIECR operation is restored. Regional Mortality and Morbidity Review System Business Continuity Plan Page 6 of 24

7 Scenario 4.2 Planned Loss of Access to NIECR, affecting access to RM&MRS Short term planned loss of access to RM&MRS will be caused by preplanned maintenance or testing on NIECR system. Actions As in scenario 4.1 Responsibilities The Regional team will provide notice regarding planned downtimes to all NIECR users via the notice board on the NIECR login screen. If an ECR release overruns time boundaries a notification will be sent to all NIECR Implementation Managers. Local Trust IT service desks will also be notified by the Regional team in advance of planned downtimes, to enable them to inform users via standard Trust procedures. Communication Resolution on System Restoration Users will be informed of the planned downtime via Trust-wide communications and the notice board on the NIECR login screen. As in scenario 4.1 Regional Mortality and Morbidity Review System Business Continuity Plan Page 7 of 24

8 Scenario 4.3 Unplanned Loss of individual aspects of NIECR Unplanned loss of individual aspects of NIECR may be caused by specific issues in the individual system that feed NIECR (e.g. server downtime) or by downtime in the services that link the feeder systems to NIECR e.g. Rhapsody Integration. Rhapsody Integration is responsible for channelling information from the various feeder systems to NIECR and RM&MRS. It generates the RM&MRS documentation into the Clinical Document View and therefore downtime in this service will prevent the generation of the MCCD and/or the Coroner s Clinical Summary and the Child Death Notification Form. Users should note that during downtime of individual feeder systems, (e.g. PAS, LABS) historical information relating to that feeder system will continue to be available within NIECR and RM&MRS. Actions In the event of unplanned loss of access to individual aspects of NIECR users should, Inform the local Trust IT service desk who will, where required, pass the call directly to the Regional NIECR team. Rhapsody Integration related unavailability Initial Record of Death (IRD) Completion of the IRD can be performed; however, the production of the MCCD and/or Coroner s Clinical Summary into the Clinical Document View may be delayed until service is resumed. Therefore, if advised that the loss of access will be short-term (a matter of hours) you may choose to wait until normal service is resumed. If loss of access is for a longer period or where a MCCD is urgently required, staff will: Complete the MCCD manually using the MCCD book and/or complete the Coroner s Clinical Summary recorded onto the WORD version Template. (Appendix 2) Advise the Mortuary verbally of MCCD completion. /fax the required documentation to the Coroner s Office. Consultant Review Form The Consultant Review Form can be completed; however, access to the MCCD/Coroner s Clinical Summary may not be available to view. You may therefore wish to defer completion until normal service is resumed. Regional Mortality and Morbidity Review System Business Continuity Plan Page 8 of 24

9 Patient M&M Review Generally, M&M reviews can still be performed, however, access to some up-to-date clinical information may not be available, although historical information will be available. Responsibilities Child Death Notification Form Production of the Child Death Notification Form may be delayed until service is resumed. The responsible Governance/Audit team should be informed of the potential delay. A WORD version of the form is available if required at Appendix 5. Contact details for Governance/Audit team Anne Quinn : Raymond Haffey : Terri Harte: or (8.30am-2.30pm) The local Trust IT service desk will determine whether the issue is Local or Regional. For a Local system issue the responsibility lies with the local Trust IT support team, who will work to resolve the issue within standard timescales. Where the issue is Regional, the local Trust IT support team will pass the call onto the Regional NIECR team by contacting the BSO Helpdesk on or by logging a request via Infra (SHSCT, SEHSCT or NHSCT) or by using the supportteam@hscni.net (BHSCT and WHSCT). The Regional team will work to resolve the issue within the agreed timeframes and will provide feedback to all local Trust IT support teams and NIECR Implementation Managers for dissemination to the affected users. Communication Resolution on System Restoration Where possible, Trust-wide communications will be sent to system users to inform them of the issue. Users will be notified when the system access is restored via Trustwide communications and the notice board on the NIECR login screen. Initial Record of Death (IRD) Print MCCD for issue to the next of kin, if handwritten form not already issued. If a handwritten MCCD was issued, complete the IRD Form when the system access returns to normal, including entering the exact terms used on the handwritten MCCD, if not Regional Mortality and Morbidity Review System Business Continuity Plan Page 9 of 24

10 completed already. Enter the same details into the SBAR boxes of the IRD as used in the WORD Template of the Coroner s Clinical Summary, if not completed already. Both the MCCD and the Coroner s Clinical Summary will appear into the Clinical Document View once the IRD has been completed. Alternatively, a copy of the WORD version of the Coroner s Clinical Summary can be added to the patient record by following the Attach a Document guidance at Appendix 6. Consultant Review Form Complete the Consultant Review Form when the system access returns to normal. Child Death Notification Form Child Death Notification Form will appear in the Clinical Document View for printing. Regional Mortality and Morbidity Review System Business Continuity Plan Page 10 of 24

11 Scenario 4.4 Planned Loss of individual aspects of NIECR Short term planned loss of individual aspects of NIECR will be caused by planned downtime in the integration process that links the feeder systems to NIECR maintenance e.g. Rhapsody Integration or testing on NIECR system. If feeder systems are unavailable then the patient record may not be fully up to date. If your local Trust IT support team advises that the Rhapsody or other feeder systems are unavailable you should follow the actions below. Rhapsody Integration is responsible for channelling information from the various feeder systems to NIECR and RM&MRS. It generates the RM&MRS documentation into the Clinical Document View and therefore downtime in this service will prevent the generation of the MCCD and/or the Coroners Clinical Summary and the Child Death Notification Form. Actions Responsibilities Rhapsody Integration related unavailability As in scenario 4.3 In accordance with the NIECR Business Continuity Plan, local Trust IT service desks should ensure that the Regional NIECR team are made aware of any planned downtime of Trust feeder systems through the agreed channels. The Regional team will provide notice regarding any planned downtimes to all NIECR users via the notice board on the NIECR login screen and will notify users whether the unavailability relates to NIECR services or the feeder system. Local Trust IT service desks will also be notified by the Regional team in advance of planned downtimes that relate to systems from other Trust areas, to enable them to inform users of the appropriate processes via standard procedures. Full impact of Rhapsody downtime will be clearly communicated from the Regional NIECR team, particularly in respect of data entry elements of NIECR that will be affected. Local Trust IT service desks will then in turn inform all NIECR users. Communication Resolution on System Restoration Users will be informed of the planned downtime via Trust-wide communications and the notice board on the NIECR login screen. As in scenario 4.3 Regional Mortality and Morbidity Review System Business Continuity Plan Page 11 of 24

12 Scenario 4.5 Actions Patient Record Locked Down For patients who opted out of NIECR, their account remains locked when they are deceased. There would need to be a justifiable reason why the patients option to opt-out would be overruled. In these instances the process will need to be managed manually: MCCD/Coroner s Clinical Summary will need to be handwritten and issued, a copy should be kept in the clinical notes of the deceased; The Consultant should complete the Consultant Review by consulting the clinical notes and signing the copy of the MCCD; the original having been given to the Informant. The M&M Review will need to be completed manually based on the clinical notes, all learning lessons and associated actions will need to be recorded onto the WORD version of the M&M Review Template. (Appendix 4). Scenario 4.6 Non-resident of Northern Ireland If the deceased is a non-resident of NI, once an administrator has created a record in Symphony/eEMS with a temporary Health & Care Number, the record should generally appear in NIECR within 30 minutes. The addition of further patient details is required via PAS. Once this is complete, the deceased can be enrolled onto the Mortality Pathway. Actions If the record is not available or where an MCCD is urgently required: Complete the MCCD manually, copy and place on to the clinical notes. Once the record is available, enrol the deceased onto the NIECR Mortality Pathway, entering the exact terms used on the handwritten MCCD. The remaining Pathway forms can be completed as per usual. Regional Mortality and Morbidity Review System Business Continuity Plan Page 12 of 24

13 5. Implementation The RM&MRS Business Continuity Plan will be stored along with and be accessible via the same process as current Trust continuity documentation. 6. Monitoring Arrangements The Department of Health is responsible for the overall monitoring of this policy. 7. Links to Other Policies The RM&MRS BCP should be read in conjunction with the NIECR BCP and local Trust policies and procedures. Regional Mortality and Morbidity Review System Business Continuity Plan Page 13 of 24

14 NIECR Feeder Systems (as of June 2013) Appendix 1 Feeder System Patient Administration Systems (PAS) Managed/Updated by Regional PAS systems Patient Centre Clinical Documents Regional Patient Centre systems Emergency Care Summary (ECS) GP Practices (Region wide) Laboratory Systems Regional LABS systems Clinisys Master Labs system Emergency Department Systems Radiology Information Systems (RIS) Regional NIRAES system Symphony system eems Regional Sectra RIS RVH Philips RIS BCH GE RIS Health and Care KEY Index BSO PACS (Radiology Images) Future development to view images (all 3 PACS) Regional Mortality and Morbidity Review System Business Continuity Plan Page 14 of 24

15 Appendix 2 Clinical Summary WORD Template Name of Patient: H&C number: DOB: Address: Date of Death: Postcode: Place of Death Hospital: Ward: CLINICAL - SBAR Details Situation: Brief description of admission, diagnosis Include reason for referral to Coroner. Background: Past Medical History, Medications Include length of each current medical condition, any alcohol & drug abuse, any blood borne virus disease Background: Describe Clinical Course Background: Procedural details, surgery, investigations Coroner Details Coroners Reference Number: - Coroner Contacted by: Regional Mortality and Morbidity Review System Business Continuity Plan Page 15 of 24

16 Date and Time Coroner Contacted: Record of Discussion with Coroner: Doctor Details Doctor s Name: Work Address: GMC number: Work Contact No: Date: Implants Does the deceased have any implanted cardiac device which is still implanted e.g. cardiac pacemaker, cardioverter-defibrillator (ICD), ventricular assist device? Yes / No Does the deceased have a Radio-active implant which is still implanted? Yes / No Does the deceased have any other hazardous device which is still implanted or not made safe e.g. Expandable Intramedullary nail - FIXION( ) nail; battery powered implant? Yes / No Regional Mortality and Morbidity Review System Business Continuity Plan Page 16 of 24

17 Contacting the Coroner Appendix 3 Online Contacting the Coroner s Office Web Address Laganside House Oxford Street Belfast BT1 3LA Telephone: Fax: deathreportingteam@courtsni.gov.uk Notifying the coroner of a Death Section 7 of the Coroners Act (Northern Ireland) places a duty, on amongst others, medical practitioners to report a death in certain circumstances. Deaths that must be reported to the coroner The duty to report arises if a medical practitioner has reason to believe that the person died directly or indirectly: from natural illness or disease if the deceased had not been seen and treated for it by a registered medical practitioner within 28 days prior to death; as a result of violence, misadventure or by unfair means; as a result of negligence, misconduct or malpractice (e.g. deaths from the effects of hypothermia or where a medical mishap is alleged); from any cause other than natural illness or disease e.g.: homicidal deaths or deaths following assault, road traffic accidents or work related accidents; injury, direct or indirect (including birth injury); deaths associated with the misuse of drugs (whether accidental or deliberate); or any apparently suicidal death, the cause of death was as a result of an industrial or occupational disease,; as the result of the administration of an anaesthetic, e.g. hypoxia, circulatory failure, drug reaction; as the result of an operation, following a medical procedure or where a person has had an accident or adverse incident in the hospital environment; the death occurred in other circumstances that may require investigation e.g.: the death, although apparently natural, was unexpected Sudden Unexpected Death in Infancy (SUDI) Regional Mortality and Morbidity Review System Business Continuity Plan Page 17 of 24

18 Trust Logo or Name Appendix 4 Patient M&M Review - WORD Template for use when unable to access NIECR M&M Team Name: M&M Lead: Date of Meeting: Name of Patient: H&C number: Nominated for Detailed Review: Details of Discussion: "[Details of discussion]" Yes No Lessons Learned (1): Detail Category Actions Agreed: Action(s) Agreed Responsible Team Responsible Individual Date Action to be Completed Lessons Learned (2): Detail Category Regional Mortality and Morbidity Review System Business Continuity Plan Page 18 of 24

19 Actions Agreed: Action(s) Agreed Responsible Team Responsible Individual Date Action to be Completed Lessons Learned (3): Detail Category Actions Agreed: Action(s) Agreed Responsible Team Responsible Individual Date Action to be Completed Learning Lesson Categories: 1. Monitoring the Deteriorating Patient 6. Operation/Invasive procedure/resuscitation 2. Diagnostic & Assessment 7. Patient Flow/Pathway 3. Prevention 8. Equipment Related 4. Medication/Fluid 9. Other type (not fitting into above categories) 5. Infection Control 10. Good Practice for Dissemination Outcome (place X in appropriate box): The care provided in the management of this patient, 1. Was satisfactory. There were no particular Learning Lessons. 2. Contained aspects that COULD 1 be improved (learning identified); the patients eventual outcome was NOT affected. 3. Contained aspects that SHOULD 2 be improved (learning identified); the patient s eventual outcome was NOT affected i.e. Near Miss. Consider referring to Trust Incident Reporting System unless already considered or reported. 4. Contained aspects that have already been, or SHOULD 2 be, referred to Trust Incident Reporting System. 5. Contained aspects that were Exemplary and the learning SHOULD 2 be shared appropriately. 1 Opinion may be divided and there may be issues that required debate. 2 General agreement that issues and learning have been identified and change is needed. Regional Mortality and Morbidity Review System Business Continuity Plan Page 19 of 24

20 Appendix 5 1. CHILD S DETAILS Date of birth Child Death Notification form 2. DETAILS OF THE DEATH Hospital / Place of death name Ward Date of Death Time: Death in the Community or outside NI Brief clinical details Admission diagnosis 3. OUTCOME MCCD details (if known) MCCD Cause of Death Interval Ia Ib Ic II 4. OUTCOME - CORONER details Coroner contacted discussed MCCD issued. Coroner notified: - for Coroner s PM. Date Date Regional Mortality and Morbidity Review System Business Continuity Plan Page 20 of 24

21 Coroner notified: MCCD/proforma requested. Date Cause of Death 5. FURTHER QUESTIONS Was there an expectation, realised at the time of admission, that this patient would die during this admission? Further details. Did the patient receive palliative End of Life Care? Did the patient receive treatment from the multi-disciplinary Specialised Palliative Care Team? 6. MORTALITY & MORBIDITY MEETING DETAILS M&M meeting date Discussion details Lesson learned Action agreed Lesson learned Action agreed Lesson learned Action agreed Lesson learned Action agreed Lesson learned Action agreed 7. FINAL CATEGORISATION Regional Mortality and Morbidity Review System Business Continuity Plan Page 21 of 24

22 Categorise death using the scale below The care provided in the management of this patient, 1. was Satisfactory. There were no particular Learning Lessons. 2. contained aspects that COULD* be improved (learning identified); the patient s eventual outcome was NOT affected. 3. contained aspects that SHOULD be improved (learning identified); the patient s eventual outcome was NOT affected i.e. Near Miss. Consider referring to Trust Incident Reporting System unless already considered or reported. 4. contained aspects that have already been, or SHOULD, be referred to Trust Incident Reporting System. 5. contained aspects that were Exemplary and the learning SHOULD be shared appropriately. * Opinion may be divided and there may be issues that required debate. General agreement that issues and learning have been identified and change is needed. 8. SERIOUS ADVERSE INCIDENT (SAI) REFERRAL Has a SAI previously been reported? Following a M&M review, has a SAI needed to be reported? 9. REPORTER DETAILS Date of Completion Full name Title Organisation: Tele: address Please return this form to: cdnotifications@hscni.net Regional Mortality and Morbidity Review System Business Continuity Plan Page 22 of 24

23 Process for Attaching a Document Appendix 6 Reasons for As part of the review of some deaths you may wish to attach a document to the patient RM&MRs record, this must be a PDF document. Anyone with the relevant access to Pathways within ECR may attach a document including consultants, trainees, other medical staff and governance staff. Types of document you may wish to attach to a patient s RM&MRs pathway include: Coroner s verdicts, SAI reports, pathology reports, Post Mortem report etc. Please note that only records centred on a patient should be attached to that patient s pathway. ECR is a patient based system so wider ranging documents e.g. safety alerts/graphs should not be attached to a patient pathway. Attaching a Document Find the patient you wish to attach a document to either through the Patient Search or Recently Viewed Patients tabs along the left-hand side. Once you have selected the patient, if you are an information governance or litigation staff member, you must complete the consent screen to obtain access to the patient record choosing Information Governance as the subject and completing the additional details box with the reason access is required, access will then be granted. Once the patient summary appears, click on the Pathways tab along the top of the screen. The patient should already be on the Mortality pathway as they need to be on the pathway for the death to have been registered. Click on the + button at the top-left of the screen beside Patient Tasks, select Attach a Document from the drop-down list and click Add Task. An Attach a Document tab will pop-up on the left-hand side of the screen under the Mortality Pathway heading. Click on this. Select the document type from the drop-down list then click browse. Select the document you want to attach then either double-click on it or click Open and the document should appear. Click Complete to attach this. The document will be saved under that particular Attach a Document tab where it can be accessed at any time. If you are experiencing any issues attaching a document please contact: NIECR via the Infra portal (SHSCT, SEHSCT & NHSCT) or supportteam@hscni.net (BHSCT & WHSCT Regional Mortality and Morbidity Review System Business Continuity Plan Page 23 of 24

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