Serious Incident Management CCG Policy Reference: SIM 001. This policy replaces or supersedes Policy Ref SIM 001

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1 Serious Incident Management CCG Policy Reference: SIM 001 This policy replaces or supersedes Policy Ref SIM 001 Target Audience Brief Description (max 50 words) Action Required Governing Body members, sub-committee members, all staff working for, or on behalf of the NHS North West Surrey CCG (NWS CCG) and NWS CCG providers. This policy sets out the principles by which the CCG will develop, manage and review all Serious incidents It is the duty of NWS CCG to establish and maintain robust arrangements for monitoring and performance managing SIs reported by services commissioned by NWS CCG. NWS CCG is committed to this policy through the implementation of a robust consistent approach for the management of SIs. This policy is a living document and will be reviewed in line with specified review dates or when a national or local change occurs. As the system learns and matures, relevant changes will be considered and made where appropriate. The Head of Corporate Service Manager will establish and maintain a corporate register of all policies and their status, and will ensure that these are appropriately reflected on the website. Document Title: Serious Incident Management v4 Issue Date: April 2014 Reviewed and updated: February 2018 Next review date: February 2020 Page 1 of 29

2 Reader Information Title Policy Register Number Rights of Access Type of formal paper Category Format Language Document purpose and description Serious Incident Management SIM001 Private Policy & Procedure Word Document English This document provides a framework for the management of serious incidents Name & Title of Author(s) Initial policy written by the Quality Team at South London Clinical Commissioning Support Unit (SLCSU). Revised in October 2013, March 2014, September 2015 and February 2018 by Caroline Simonds, Quality and Patient Safety Manager, NHS North West Surrey CCG Publication Date Initial publication 14 March revised as outlined above Dissemination and This policy will be disseminated and implemented as outlined below: Implementation details NHS North West Surrey CCG Quality Team will disseminate the contents of the policy within the CCG and to its commissioned services. Responsibility for NHS North West Surrey CCG Quality Team implementation Review Date February 2020 Disposal Date As per CCG processes Target Audience NWS CCG and Providers Circulation List Consultation Process Refer to version control References Serious Incident Framework / Never Events Framework National Patient Safety Agency (NPSA) Seven Steps to Patient Safety. The full reference guide. Available at March 2010 Department of Health DH (2004) Memorandum of Understanding: investigating Patient Safety Incidents National Patient Safety Agency (2009) Being Open communicating patient safety incidents with patients, their families and carers. Superseded Document N/A Financial Resource None Page 2 of 29

3 Implications Ratification History Version Date Committee/Group Outcome 2 October 2013 Governing Body Approved 3 April 2014 Policy Sub Group Approved 4 September 2015 Quality Committee, Clinical Executive & Policy subgroup Reviews being undertaken in September Document Review Control Information Version and Status Date of Change Title of reviewer Draft Jan 2013 April 2013 April 2013 April 2013 May 2013 June 2013 SLCSU Senior Nurse & Clinical Governance Lead NHS NW Surrey CCG Head of Quality/ Chief Nurse NHS NW Surrey CCG Director of Quality and Innovation NHS North West Surrey CCG Quality and Performance Committee members NHS North West Surrey CCG Clinical Executive Committee members Version 1 July 2013 NHS North West Surrey CCG Governing Body Version 2 October 2013 NHS North West Surrey Quality Team Version 3 April 2014 NHS North West Surrey Quality Team Version 4 September 2015 NHS North West Surrey Quality Team Version 5 February 2018 NHS North West Surrey Quality Team Description of Change First version of this policy Comments reflected in the policy Comments reflected in the policy Comments reflected in the policy Addition of reference to Surrey Safeguarding Adults and Children s processes. Policy approved Amendments to reflect the transition of the Quality team from SLCSU to NHS North West Surrey CCG (NWS CCG) Amendment to the policy to reflect the new SI closure process Amendment to reflect the revised NHS England 2015/16 SI Framework & Never Events list Amended to reflect revised national Never Event Guidance and Never Event list 2018/19 Equality Impact Assessment (EIA) Page 3 of 29

4 NWS CCG aims to design and implement services, policies and measures that meet the diverse needs of their service and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact Assessment is designed to help staff consider the needs and assess the impact of the policy. Policy author(s) must undertake this assessment. Initial assessment Yes/No Comments Does this document affect one group less or more favourably Considerations has than another on the basis of: been made to Race Ethnic origins (including gypsies and travellers) Nationality Yes presenting the format of this document to comply with & to Gender provide alternative Culture Religion or belief medians i.e. Large print and audio, Sexual orientation including lesbian, gay and bisexual people Age Disability learning disabilities, physical disability, sensory impairment and mental health problems Is there any evidence that some groups are affected No differently? If you have identified potential discrimination, are there any No exceptions valid, legal and/or justifiable? Is there a need for external or user consultation Yes Is the impact of the document likely to be negative? No If so, can the impact be avoided What alternatives are there to achieving the document without the impact? Can we reduce the impact by taking different action? Where an adverse or negative impact on equality groups) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the NWS CCG Quality Manager 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 the Director of Corporate Development and Assurance Was a full impact assessment required? What is the level of impact? No Low Page 4 of 29

5 CONTENTS SECTION 1: NHS NORTHWEST SURREY SERIOUS INCIDENT POLICY... 6 Equality Statement INTRODUCTION PURPOSE OF THE POLICY SCOPE DEFINITION OF A SERIOUS INCIDENT (SI) ROLES AND ACCOUNTABILITIES DISSEMINATION OF LEARNING MONITORING COMPLIANCE AND EFFECTIVENESS SECTION NHS IMPROVEMENT REVISED SERIOUS INCIDENT FRAMEWORK AND NEVER EVENT GUIDANCE SECTION Appendix A NWS Provider Serious Incident Management Process Appendix B NHS North West Surrey Serious Incident Closure Panel Appendix C Notification Form Appendix D- Serious Incident Requiring Investigation (SIRI) 72 Hour Report Appendix E - Information required by the Department of Health for Category 3+ Information Governance SUIs Appendix F - Surrey Safeguarding Adult Clinical Governance and Safeguarding Flowchart. 29 Page 5 of 29

6 SECTION 1: NHS NORTHWEST SURREY SERIOUS INCIDENT POLICY Equality Statement NWS Clinical Commissioning Group aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the Equality legislation including the Human Rights Act 1998 and promotes equal opportunities for all. This document has been assessed to ensure that no employee receives less favourable treatment on grounds of their protected characteristics including age, disability, gender, gender reassignment, marriage and civil partnership, race, religion and belief, sex and sexual orientation. Members of staff, volunteers or members of the public may request assistance with this policy if they have particular needs. If the member of staff has language difficulties and difficulty in understanding this policy, the use of an interpreter will be considered. 1. INTRODUCTION This policy outlines the systems and processes within which serious incidents will be reported and managed. It applies to serious incidents reported by NHS North West Surrey CCG (NWS CCG) and organisations for which NHS North West Surrey CCG is lead commissioner. NWS CCG will work with other CCGs and Commissioning Support Units in relation to serious incidents reported by other providers for which the CCG is not the lead commissioner (eg. Surrey and Borders Partnership Trust, other acute and community providers). The vast majority of patients receive high standards of care, however incidents do occur and it is important they are reported and managed effectively. NHS North West Surrey Clinical Commissioning Group (CCG), is committed to promoting patient safety and making an effective contribution to the CCG s vision of no avoidable deaths, injury or illness and no avoidable suffering or pain. SIs in healthcare are uncommon but when they occur the NHS has a responsibility to ensure there are systematic measures in place for safeguarding people, property, NHS resources and reputation. It is the duty of NWS CCG to establish and maintain robust arrangements for monitoring and performance managing SIs reported by services commissioned by the CCG. NHS North West Surrey CCG is committed to this policy through the implementation of a robust consistent approach for the management of SIs. NHS North West Surrey CCG will ensure that appropriate management systems are in place across North West Surrey CCG Commissioned providers to: To comply with the requirements of the NHS England Serious Incident Framework 2015/16 (including the 2015/16 Never Events Policy); Report all SIs in a timely fashion and without prejudice; Have systematic measures in place to robustly and effectively manage SIs. Page 6 of 29

7 Ensuring actions are taken to improve quality and safety and to minimise the risk of future reoccurrences; Share the learning. Intelligence gained from SIs will be used to influence contract monitoring, quality and safety standards for care pathway development and service specifications. Reporting SIs is a legal requirement under CQC regulations. Therefore all SIs, including Never Events must be reported to the CQC. This requirement continues regardless of the organisational changes within the NHS. Serious incident (including Never Events) reporting requirements are specified in the contracts with all providers. 2. PURPOSE OF THE POLICY The purpose of this policy is to describe the NWS CCG framework for reporting and managing SIs reported by NHS North West Surrey CCG Commissioned Organisations. The NWS CCG Serious Incident Management Policy is aligned to the NHS England Revised Serious Incident Framework published in April The policy aims to ensure that North West Surrey CCG complies with current legislation, National Guidance and the NHS England SI Framework with regard to SI reporting, investigation evaluation of the management process. The full NHS England SI Framework is provided in Section 2. A diagrammatic summary of the NHS North West Surrey SI Management Process is provided in Appendix A. This policy is a living document and will be reviewed in line with specified review dates or when a national or local change occurs. As the system learns and matures, relevant changes will be considered and made where appropriate. This policy does not interfere with existing lines of accountability and does not replace the duty to inform the police, Safeguarding Teams and/or other organisations or agencies where appropriate and required. Further guidance can be obtained from the NHS England revised Serious Incident Framework (see Section 2). 3. SCOPE This policy applies to NHS North West Surrey CCG and all providers for whom NHS North West Surrey CCG is the lead commissioner. 4. DEFINITION OF A SERIOUS INCIDENT (SI) In broad terms, serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and Page 7 of 29

8 include incidents which may indirectly impact patient safety or an organisation s ability to deliver on going healthcare. The occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved. Serious incidents therefore require investigation in order to identify the factors that contributed towards the incident occurring and the fundamental issues (or root causes) that underpinned these. Serious incidents can be isolated, single events or multiple linked or unlinked events signalling systemic failures within a commissioning or health system. There is no definitive list of events/incidents that constitute a serious incident and lists should not be created locally as this can lead to inconsistent or inappropriate management of incidents. Where lists are created there is a tendency to not appropriately investigate things that are not on the list even when they should be investigated, and equally a tendency to undertake full investigations of incidents where that may not be warranted simply because they seem to fit a description of an incident on a list. The definition below sets out circumstances in which a serious incident must be declared. Every incident must be considered on a case-by-case basis using the description below. Inevitably, there will be borderline cases that rely on the judgement of the people involved. Serious Incidents in the NHS include: Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in: Unexpected or avoidable death of one or more people. This includes: o suicide/self-inflicted death; and o homicide by a person in receipt of mental health care within the recent past. Unexpected or avoidable injury to one or more people that has resulted in serious harm; Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent: the death of the service user; or serious harm; Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where: healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or where abuse occurred during the provision of NHS-funded care. This includes abuse that resulted in (or was identified through) a Serious Case Review (SCR), Safeguarding Adult Review (SAR), Safeguarding Adult Enquiry or other Page 8 of 29

9 externally-led investigation, where delivery of NHS funded care caused/contributed towards the incident. A Never Event - all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death. See Never Events Policy and Framework for the national definition and further information An incident (or series of incidents) that prevents, or threatens to prevent, an organisation s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following: o o o o o o Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues. Property damage. Security breach/concern. Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population; Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act. Deprivation of Liberty Safeguards (MCA DOLS). Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services or activation of the Major Incident Plan by provider, commissioner or relevant agency. Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation. Assessing whether an Incident is a Serious Incident In many cases it will be immediately clear that a serious incident has occurred and further investigation will be required to discover what exactly went wrong, how it went wrong (from a human factors and systems-based approach) and what may be done to address the weakness to prevent the incident from happening again. Whilst a serious outcome (such as the death of a patient who was not expected to die or where someone requires on going/long term treatment due to unforeseen and unexpected consequences of health intervention) can provide a trigger for identifying serious incidents, outcome alone is not always enough to delineate what counts as a serious incident. The NHS strives to achieve the very best outcomes but this may not always be achievable. Upsetting outcomes are not always the result of error/ acts and/ or omissions in care. Equally some incidents, such as those which require activation of a major incident plan for example, may not reveal omissions in care or service delivery and may not have been preventable in the given circumstances. However, this should be established through thorough investigation and action to mitigate future risks should be determined. Page 9 of 29

10 Where it is not clear whether or not an incident fulfils the definition of a serious incident, providers and commissioners must engage in open and honest discussions to agree the appropriate and proportionate response. It may be unclear initially whether any weaknesses in a system or process (including acts or omissions in care) caused or contributed towards a serious outcome, but the simplest and most defensible position is to discuss openly, to investigate proportionately and to let the investigation decide. If a serious incident is declared but further investigation reveals that the definition of a serious incident is not fulfilled- for example there were no acts or omissions in care which caused or contributed towards the outcome- the incident can be downgraded. This can be agreed at any stage of the investigation and the purpose of any downgrading is to ensure efforts are focused on the incidents where problems are identified and learning and action are required (see Part Three, section 3 for further details relating to reporting). Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare provider and guidance on the events classified as never events is outlined Section 2. As a minimum, patient safety incidents leading to unexpected death or severe harm should be investigated to identify root causes and enable ameliorating action to be taken to prevent recurrence. The definition of SIs requiring investigation extends beyond those which affect patients directly, and includes SIs which may indirectly impact on patient safety or a commissioned providers ability to deliver on going healthcare. The NHS England 2018 Never Event list is provided in Section 2 5. ROLES AND ACCOUNTABILITIES Both commissioning and commissioned providers, whether in primary, secondary or tertiary care, are accountable for effective governance and learning following a serious incident. The precise split of responsibilities between organisations varies with the type of provider and commissioner, and the particular circumstances of each serious incident. Each Commissioned Provider is contractually required to comply with the SI reporting and investigation requirements within the NHS England SI Framework. Outlined below is a summary of the key roles and accountabilities both for individuals and committees within NHS North West Surrey CCG. 5.1 NHS North West Surrey CCG Managing Director is accountable for ensuring the CCG has the necessary management systems in place to enable the effective implementation of SI management within North West Surrey CCG. 5.2 Surrey Heartland Executive Director of Quality is the appointed Director with responsibility for monitoring the effective management of SIs across all Surrey Heartlands CCGs. 5.3 NHS North West Surrey CCG Quality and Patient Safety Manager of Quality is responsible for ensuring there is effective management of SIs Page 10 of 29

11 o o o o o o Surrey Heartland Executive Director of Quality is responsible for providing clinical advice and leadership and ensuring through the work that: Commissioned organisations have robust systems and processes for prompt reporting and management systems for SIs, Performance monitoring of commissioned organisations reported SIs is robust, NWS CCG s Governing Body, Clinical Executive and Quality Committee are assured on the performance management of SIs within commissioned organisations and the CCGs overall Serious incident management process, NHS England, other stakeholder CCGs and/or relevant professional bodies are informed of the relevant SIs, Informing the NHS England (South East) Regional Team when an SI originates in or involve the actions of the CCG and ensuring a robust investigation is undertaken. 5.4 NHS North West Surrey CCG Clinical Lead for Quality and Medicines Management will provide expert clinical review of serious incidents and advise Clinical Executive, Quality Committee and Governing Body on clinical issues and concerns requiring action. 5.5 Governing Body: is to be assured through Clinical Executive and Quality Committee that there are systems in place within NHS North West Surrey CCG and its commissioned services to provide a robust framework for serious incident management. 5.6 Clinical Executive: is accountable to Governing Body for assuring the CCG has a robust Serious Incident Management process in place and that the clinical issues identified through the SI Scrutiny Panel review of SI s are being effectively managed to mitigate clinical risk. To execute its responsibilities in respect of serious incident management and to enable the committee to provide robust assurance to Governing Body, Clinical Executive has put in place a serious incident closure panel. This group leads on the review serious incidents and will report to Clinical Executive on the serious incidents approved for closure, overall performance management, trends and themes. 5.7 NHS North West Surrey CCG SI Scrutiny Panel: has delegated responsibility from Clinical Executive for the review and closure of commissioned services serious incidents. This group is also responsible for reviewing investigation reports from NHS North West Surrey CCG serious incidents investigation reports prior to their submission to the NHSE (South East) for review before closure. The terms of reference for the SI Scrutiny Panels are outlined in Appendix C. 5.8 Quality Committee (QC): The role of the Quality Committee is to provide assurance to the Governing Body that the organisation has robust incident performance management processes in place. Page 11 of 29

12 5.9 Clinical Quality Review meetings (CQRM): Will receive with serious incident Performance Management reports through Clinical Quality Review Groups assurance updates on the implementation and outcomes from SI investigation report action plans will be received along with action plans following Regulation 28 Reports (Ministry of Justice: Guidance for coroners on changes to Regulation 28: Coroner reports to prevent future deaths) and Safeguarding Children and or Adult reports. Assurance on the implementation of SI action plans will be monitored through the provider CQRM North West Surrey CCG Quality Team: Has delegated responsibility for The management of Provider SIs, through: Receiving SI notifications via STEIS; Ensuring when relevant respective CCGs are notified of SIs promptly, highlighting those that may be of higher risk and/or media interest; Maintaining an overview of SIs reported across commissioned providers allowing for identification of trends and patterns; Developing close working relationship with commissioned providers identified Quality and Safety Leads; Providing a consistent approach for the sign-off and closure of commissioned provider SIs by the CCG; A system of activities for disseminating and sharing lessons to allow for minimisation of risks and improvement of patient safety. Supporting serious incident closures within the North West Surrey serious incident management framework and reporting to Clinical Executive on the decisions taken at the NHS North West Surrey SI Scrutiny Panel. Provide regular reports on commissioned provider SIs to the CCG; Support & offer guidance to all commissioned providers to ensure they are able to comply with policy requirements. This role will be undertaken by NHS North West Surrey CCG Quality and Patient Safety Manager NWS CCG Communication Team: has responsibility for identifying a clear communication plan for working with relevant colleagues both internally and externally to support effective management of the SIs. They will work to prepare media statements, ensuring that statements are prepared for the media ensuring that patients and staff and other affected parties are informed before release of statements to the media. They will also confirm proposed handling arrangements with, where considered necessary develop communications/media handling strategies with other organisations and liaise with relevant stakeholders as appropriate. The Communications Team will design and implement a strategy for ongoing and longer-term management of communications. This should include details of key messaging, sign-off process, spokespeople and effective engagement Subject-Matter Expert Leads: (as and when required). In addition to their own suitably qualified and experienced staff, NHS North West Surrey CCG will ensure access to competent independent investigators and experienced clinical advisers who Page 12 of 29

13 can be engaged to undertake investigations when required. The role of an expert lead would be to review relevant SI alerts and identify any areas that need to be addressed as part of the investigation. When the SI report is completed, the role is then to support the Root Cause Analysis (RCA) evaluation process in ensuring that commissioned provider SIs are investigated appropriately, identify whether the investigation had addressed all the issues and is suitable for closure. Subject-matter expert leads could provide advice around medicines management, maternity, infection control, mental health, information governance, health and safety, estates etc Commissioned Providers: Providers must be compliant with the requirements identified within the NHS England SI Framework document, published in April 2015 and have a responsibility to ensure that their first priority when an SI occurs is to ensure the needs of individuals affected by the SI are attended to, including any urgent clinical care and management action that may reduce harmful impact. The commissioned provider should give early consideration to the provision of information and support to patients, relatives and carers and staff involved in the SI, including information regarding support systems which are available to patients/relatives/visitor/contractors. The commissioned provider must comply with the duty of candour requirements and the principles of being open and have an approved Being Open Policy. Commissioned providers also have the following responsibilities: Ensuring there are structured risk management systems and processes for collecting, collating and analysis of data on all SIs and lessons learned, including reporting SIs via STEIS. Those commissioned providers without access to STEIS should contact the NWS CCG Quality Team directly and report SIs using the reporting form in appendix F. Reporting SIs in accordance with the national framework. Re-establishing a safe environment where all equipment or medication involved in the SI are retained and isolated, relevant documentation copied and secured to preserve evidence and facilitate investigation and learning, Contacting the police if there is a suggestion that a criminal offence has been committed, Ensuring all SIs defined by the National SI Framework, are investigated as per national guidance, using root cause analysis (RCA) methodologies. Manage the reporting to HSE as appropriate of Health and Safety Incidents, CQC and to the NPSA through the National Reporting and Learning System (NRLS) for Patient Safety Incidents, Informing NHS North West Surrey CCG if they are considering commissioning services (or parts of) through other commissioned providers and must assure NHS North West Surrey CCG that any commissioned services are compliant with this policy. Ensuring appropriate representatives attend the NHS North West Surrey SI Scrutiny Panel Page 13 of 29

14 5.14 Involvement of more than one Commissioned Provider: When more than one commissioned provider is involved in an SI, it is the responsibility of the organisation identifying the SI to liaise with the other commissioned provider involved to agree which organisation will report on STEIS, undertake the investigation, present the findings & agree action implementation. The commissioned provider with the most significant involvement in the SI will take the lead in investigating the SI. This involves collaboration with other commissioned providers involved in the SI and/or managing the outcome. All organisations are required to contribute to the RCA investigation in a timely, responsive and cooperative manner. The NWS CCG Quality Team may be contacted to provide support, advice or assistance in brokering an agreement to identify the lead commissioned provider if this is either unclear or is disputed Quality Surveillance Groups (QSG): The National Commissioning Board have developed Quality Surveillance Groups where data, incident reports and the quality of responses to SIs that give cause for concern will be shared. This will assist in the triangulation of other quality-related information and the formulation appropriate responses, such as triggering a Risk Summit or keeping the provider under regular review. The NCB, CCGs, and NHS Improvement should fully exploit the opportunities for sharing information about SIs in relevant providers with partner organisations who make up the relevant local and regional Quality Surveillance Groups NHS England will have responsibility for: Commissioning independent investigations/inquiries into serious incident cases which meet nationally agreed criteria. Working with NHS England and Regional Teams to identify relevant intelligence and learning to be shared at national level and to facilitate such learning and sharing at a national level. NHS England will keep the SI management system under review, particularly to mitigate risks during transition and the bedding down of the new system. High level oversight of SI reporting and responses, including reviewing trends, quality analysis and early warnings via Quality Surveillance Groups will be proportionate to requirements. Provide support to contract management for primary and specialised care providers responses to SIs and, where appropriate, commissioning and co-ordinating primary and specialised care SI investigations. Have oversight of SI investigations undertaken in acute, community, mental health and ambulance care including reviewing trends, quality analysis and early warnings via Quality Surveillance Groups. Management of SIs in services directly commissioned by the NHS England will be the responsibility of the NHS England to comply with National Standards & requirements SI investigation NHS Improvement will continue to perform the function currently delivered by what was known as Strategic Health Authorities with respect to NHS Trusts in the context of the on-going transition of those organisations to Foundation Trust Status. It will also, from the 1 st April 2013 be responsible for the performance management of NHS Trusts. NHS Improvement will ensure that NHS Trusts have appropriate systems and processes in place to report, investigate and respond to SIs, be able to credibly Page 14 of 29

15 investigate and follow through on action plans in line with national policy and best practice. It will work in partnership with the relevant commissioner and /or NHS England to support them in their management of SIs. In this regard, the accountability for the management of SIs rests with commissioners facilitated by NHS Improvement TDA. NHS Improvement will use information about SIs as a component of the overall surveillance of quality, sharing information and liaising with the CQC, professional regulators, and other stakeholders especially those associated with quality surveillance groups. Have oversight of all SI investigations in NHS Trusts, coordinating responses where necessary alongside commissioners. Use relevant intelligence and information to inform their performance management of NHS Trusts and the Foundation Trust pipeline. 6. DISSEMINATION OF LEARNING One of the key aims of the serious incident reporting and learning process is to reduce the risk of recurrence, both where the original incident occurred and elsewhere in the NHS. The timely and appropriate dissemination of learning following a serious incident is core to achieving this and to ensure that these lessons are embedded in practice. Learning can be demonstrated at organisational level by sustainable changes and improvements in process, policy, systems and procedures relating to patient safety within healthcare organisations. Key learning points that may be shared more widely may fall into the following areas: understanding and identification of the influence of Human Factors; solutions to address incident root causes that may be relevant to other teams, services and provider organisations; Identification of the components of good practice that reduced the potential impact of the incident and how they were developed and supported. Systems and processes that allow early detection or intervention that will reduce the potential impact of the incident; Lessons from conducting the investigation that may improve the management of investigations in future; Documentation of identification of the risks, the extent to which they have been reduced and how this is measured and monitored. Reporting organisations and NHS North West Surrey CCG will work together to share the learning from serious incidents both within the North West Surrey healthcare system and also through Serious Incident Learning Events both at Surrey, Regional and National levels. 7. MONITORING COMPLIANCE AND EFFECTIVENESS In order to comply with the requirements of the National Framework for the reporting and Learning from Serious Incidents, commissioned organisations and NHS North West Surrey CCG must monitor trends in serious incident reporting. This trend analysis must include not Page 15 of 29

16 only a quantitative report but also a qualitative analysis of those incidents where root causes and lessons learned have been identified. On-going compliance with the requirements of the National Reporting and Learning Framework for Reporting and Learning from Serious Incidents by using the following measures: Standard Detail Data source Incidents will be reported within two working days of identification of the incident A 72 hour update report will be uploaded onto STEIS Time from date of knowledge (see section 2.2) to incident reported on Strategic Executive Information System (STEIS) Time from date of incident coming to light and completion of 72 hour update must be no more than 72 hours Strategic Executive Information System (STEIS) Strategic Executive Information System (STEIS) Incident investigations will follow the structure and process of Root Cause Analysis methodology. Understanding and analysis within the investigation should include a thorough analysis of key contributory factors to include description against these and identification and understanding of any Human Factors that may lead to wider learning. The Strategic Executive Information System (STEIS) must be kept up to date and incidents closed according to national timescales. Clinical Quality Review meetings to receive assurance on the implementation of action plans Investigation structure to follow the National Patient Safety Agency Root Cause Analysis Guidance and Template or similar robust framework determined at local level Strategic Executive Information System (STEIS) will reflect the current status of the investigation. CQRM to receive updates and outcomes on tests of effectiveness so that the robustness of actions resulting from SIs can be assured. Investigation reports Strategic Executive Information System (STEIS) CQRM papers. Provider action plan updates evidence of tests of effectiveness. Page 16 of 29

17 7.1 Key Performance Indicators Key performance indicators to be used to review the effectiveness of the incident reporting process are; Monitoring of the level of incident reporting via provider organisation s quarterly incident and Serious Incident reports Monitoring the numbers of incidents reported within 48 hours of the incident occurring Monitor completion of 72 hour updates provided on STEIS Monitoring the number of incident investigation and SIRI investigations completed within 60 days Monitoring the incidents formally closed within 6 months of date of reporting. A review of compliance against the above standards will form part of the contractual requirements for all organisations for whom NHS North West Surrey CCG is the lead commissioner. Page 17 of 29

18 SECTION 2 NHS IMPROVEMENT REVISED SERIOUS INCIDENT FRAMEWORK AND NEVER EVENT GUIDANCE 2018 Serious Incident Framework.pdf Never_Events_list_2 018_FINAL_v2.pdf Revised_Never_Eve nts_policy_and_frame Page 18 of 29

19 SECTION 3 Appendix A NWS Provider Serious Incident Management Process Serious Incident Occurs Within 2 working days Provider to engage with those involved/affected Report on STEIS Circulation of the Notification to CCG/Clinical Leads Provider to report/notify other stakeholders as required e.g. safeguarding, CQC, NHSI etc. Within 3 working days Provider to complete initial review and submit to NWS CCG. NWS CCG will liaise with others as required. NWS CCG to confirm level of investigation required 60 working days or 6 months for independent Provider undertakes internal investigation Submit Final report and Action Plan to NWS CCG NWS CCG including specialist leads & other CCGs (with relevant stakeholders) undertakes a review of the final report and action plan and ensures it meets requirements for a robust investigation 20 days SI reviewed at NWS SI Scrutiny Panel at which Providers submitting Sis for closure are present SI closed on STEIS Additional information and return to Panel SI update provided to CQRM along with issues requiring further review and action On-going Provider to bring 6/12 update on ongoing action plans Triangulation of SI Intelligence with Quality Performance and Workforce metrics Assurance reporting to Clinical Page 19 of Executive/Quality 29 Committee/Governing Body

20 Appendix B NHS North West Surrey Serious Incident Closure Panel 1. CONSTITUTION Terms of Reference 1.1 The Governing Body of NHS North West Surrey Clinical Commissioning Group (The CCG) is responsible for performance management and closure on the national reporting system (STEIS) of each investigation report into Serious Incidents (SIs) that occur within organisations to which they are the host commissioner or they have commissioned the services of independent providers. 1.2 The process for closure must be robust and auditable so that assurance around closures decisions is evident. This responsibility is under the auspices of the CCG Quality Committee, which hereby resolves to establish a sub Committee to be known as the Serious Incident Scrutiny Panel. 1.3 The purpose of the SI Scrutiny Panel is to provide assurance to Quality Committee, Clinical Executive and the Governing Body on the robustness of investigation and action-planning as a result of serious incidents, and that learning from serious incidents has been identified and shared. 1.4 The SI Scrutiny Panel will work closely with the Clinical Quality Review Meetings (CQRM), which monitors the quality of service provision within the commissioned services, to ensure an integrated, coordinated approach to the management of Serious Incidents and strengthen the assurance provided to the Quality Committee, Clinical Executive and Governing Body. 1.5 The SI Scrutiny Panel has no executive powers, other than those specifically delegated in these terms of reference. 1.6 All procedural matters in respect of conduct of meetings shall follow the Governing Body Standing Orders. 2. SCOPE 2.1 To consider for closure all serious incidents declared and investigated by provider organisations (including Independent Providers) for which NHS North West Surrey CCG is the host provider. 2.2 To receive the investigation reports for any Serious Incidents reported by the CCG and recommend a decision on closure to Quality Committee and Governing Body before submission to NHS England South, South East Region for closure. 2.3 The Serious Incident Scrutiny panel advocates the principle of system wide learning by reviewing all serious incidents as a whole system Commissioner and Provider forum including engagement with Social Care as required.

21 3. ACCOUNTABILITY 3.1 The scrutiny panel is accountable to the CCG Governing Body via the Quality Committee. 3.2 Any risks associated with the incidence of serious incidents and/or identified during the investigation will be shared, immediately where prompt action is required, and via the Clinical Quality Review Meeting, the relevant provider Contract Management Board and the Quality Committee. 3.3 The SI Scrutiny Panel is responsible for sharing information with other CCGs as appropriate for providers/ services where they are the lead commissioner 4. MEMBERSHIP 4.1 The scrutiny panel will be appointed by the Quality Committee. 4.2 The members shall be: CCG MEMBERS Clinical Lead for Quality and Medicines Management Clinical Lead for Children, Maternity and Mental Health Quality and Patient Safety Manager (Chair) Quality Lead (also provides admin support to the meeting) PROVIDER REPRESENTATION CSH Surrey - Patient Safety & Risk Lead ASPHFT Chief of Patient Safety/Deputy Medical Director ASPHFT Acting Head of Patient Safety SOCIAL CARE Safeguarding Advisor, Adult Social Care, Other Providers will attend as required Subject Matter Experts Depending on the incident, this might include leads for information governance, infection prevention and control, safeguarding children and adults, or other senior managers or specialist staff as deemed appropriate and able to provide an independent perspective. This can be done prior to the meeting and the outcome feedback at the meeting itself. Quality Lead from Other CCGs Where an SI involves a patient residing in their locality or involves a service of whom they are Host Commissioners 5. QUORACY The quorum shall be the following: At least two CCG members of which one must be a clinician and one must be a member of the Quality Committee. Representation of at least one member from ASPHFT and CSH Surrey to 21

22 attend the full meeting Representation of at least one person from any other provider presenting a serious incident for closure. 6. ATTENDANCE AND FREQUENCY OF MEETINGS 6.1 All members (or agreed nominated representatives) are expected to attend each meeting. 6.2 Meetings shall be held at both CCG and Provider sites on a rotational basis. 6.3 Meetings shall be administered by the CCG 6.4 Notes of meetings will be circulated within two weeks of the meeting been held. 6.5 Decisions made at the meetings shall be updated onto the Strategic Executive Information System (STEIS) by the Quality Governance Support Officer within three working days of the meeting. 6.6 Ongoing monitoring of actions, issues and audits resulting from SI investigations will be undertaken through the Provider Clinical Quality Review Meetings with reporting to Contract Management Board and Quality Committee as required. 7. AUTHORITY 7.1 The Serious Incident Scrutiny Panel is authorised by the CCG Governing Body via the Quality Committee to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any requests made by the scrutiny panel. 8. DUTIES 8.1 To review all serious incident investigation reports from the organisation/ trust to assess the quality of the investigation, report and action plan, in line with national best practice guidelines and local Serious Incident policies, and to identify opportunities for wider learning. 8.2 To agree that recommendations arising from investigations are robust, feasible and meet the patient safety and quality requirements of the CCG as a commissioner. 8.3 To assess the processes in place to implement the action plan, follow up on any outstanding matters and disseminate of organisational learning (internally and in the wider health economy). 22

23 8.4 To provide challenge where appropriate and request re-submission of reports deemed unsatisfactory within an agreed timescale. 8.5 Provide a forum for reviewing and scrutinising any joint investigations for which the organisation/ Trust may not be the lead organisation/ Trust. 8.6 To receive copies of SI reports pertaining to NW Surrey residents but reviewed for closure through other CCG closure panels, so that learning can be shared within the local healthcare system. 9. REPORTING 9.1 The SI Scrutiny Panel will report a summary of the outcomes from the meeting and monitor action plans through provider Clinical Quality Review meetings in order to highlight any significant areas or issues for concern and also to the Quality Committee through the SI paper. 9.2 The SI Scrutiny Panel will circulate monthly position statements of provider open, closed and overdue SIs to Provider CQRMs (ASPHFT and CSH Surrey) to ensure timely sharing of learning and themes and updates for CCG Quality Reports 9.3 The SI Scrutiny Panel is responsible for immediate sharing of risk issues or learning that require prompt action or awareness 9.4 The SI Scrutiny Panel will report to the Quality Committee as part of the serious incident report received at each meeting. The report will include a summary of the reports reviewed in the period, and opportunities for wider learning that require further discussion and action, as well as progress on implementation of action plans. The action notes from the SI Scrutiny Panel will also be received by NWS CCG Clinical Executive as part of the Quality Surveillance Report. 9.5 The Chair of the SI Scrutiny Panel shall draw to the attention of the Providers Clinical Quality Review Meetings, Quality Committee and Governing Body, any issue that require immediate disclosure to those bodies. 9.6 An Annual Serious Incident Report shall be produced and presented to Clinical Executive, Quality Committee and Governing Body. Date of Review: May 2017 Next Review Due: May

24 Appendix C Notification Form SERIOUS INCIDENT 48 HOUR NOTIFICATION FORM Type of Incident Select one Location of Incident Time of Incident Never Event Select one Reporter Name Reporter Tel Reason for Reporting Select one Date of Incident Click here to enter text Date Incident Identified Reporting Organisation Reporter Job Title/Role Reporter Name of Other Organisations Involved (where relevant): eg hospital, ambulance service, OoH, Care Home, Mental Health Services, Police, NRLS etc Have you Reported to NRLS? (if not why not) Select one Care Sector: eg General Practice, Pharmacy, Optometrists, Mental Health, Other (if other please specify) 24

25 PATIENT DETAILS This information should only be submitted if this form is transmitted via a secure transmission ie. NHS.net account. Please do not include patient name or other patient identifier. Patient Date of Birth Patient Gender Patient Ethnic Group Patient Registered GP Practice Legal Status of Patient Type of Patient Select One Select One Select One WHAT HAPPENED? Description of What Happened Immediate Action Taken Any Further Information Where is Patient at Time of Reporting? Details of any Police/Media Involvement/Interest Any other Organisations Notified (eg MHRA, CQC, CCG etc) Details of Contact with or Planned Contact with Patient / Family or Carers 25

26 Appendix D- Serious Incident Requiring Investigation (SIRI) 72 Hour Report SIRI Reference Number: STEIS Identification Number: Report completed by: Designation: Date / Time report completed: Date of Birth: Date/Time/ Place of Incident: Incident Type: Diagnosis (currently being treated for) Description of Incident: Details of any police or media involvement/interest: Immediate Actions Taken including actions to mitigate any further risk: Details of other organisations/individuals notified: Commissioning PCT 26

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