MORTALITY AND MORBIDITY REVIEW POLICY

Transcription

1 MORTALITY AND MORBIDITY REVIEW POLICY Document Author Written By: Executive Medical Director Authorised Authorised By: Chief Executive Date: May 2017 Date: 8 th August 2017 Lead Director: Executive Medical Director Effective Date: 8 th August 2017 Review Date: 7 th August 2018 Approval at: Corporate Governance & Risk Sub-Committee Date Approved: 8th August 2017 Page 1 of 22

2 DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue 20 May March May Aug August 2017 Version. Date Approved Director Responsible for Change May 14 Executive Medical Director 1.1 Executive Medical Director 1.1 Executive Medical Director Aug 17 Executive Medical Director Aug 17 Executive Medical Director Nature of Change Ratification / Approval Final Version Update To be ratified Approved subject to EIA completion for 1 year Update of EIA Approved at Policy Management Group To be ratified at QGC Clinical Standards Group Corporate Governance & Risk Sub-Committee Corporate Governance & Risk Sub-Committee NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust Page 2 of 22

3 Contents Page 1. Executive Summary 4 2. Introduction 4 3. Definitions 4 4. Scope 5 5. Purpose 5 6. Roles & Responsibilities 5 7. Policy Detail / Course of Action 7 8. Consultation 9 9. Training Monitoring Compliance and Effectiveness Links to other Organisational Documents References Appendices 10 Appendix A Mortality Review Group Terms of Reference 11 Appendix B Mortality Review Template 14 Appendix C Mortality Outlier Rapid Review 16 Appendix D Financial and Resourcing Impact Assessment 18 Appendix E Equality Impact Assessment (EIA) Screening Tool 20 Page 3 of 22

4 1 Executive Summary Routine review of deaths or patients coming to harm or near misses is a vital element of Trust governance promoting safety of care for our patients. Use of Dr Foster Intelligence, The Summary Hospital-level Mortality Indicator (SHMI), monthly review of all deaths, coroner and Serious Incident Requiring Investigation (SIRI) review allows a cross check of performance by the Mortality Review Group, which supports routine surveillance of morality. The Group reports to SEE, QGC and Trust Board. Morbidity data should be reviewed through relevant Clinical Business Unit Quality Groups and then, as necessary, to our Trust overarching Quality Governance Committee. 2 Introduction The policy supports assurance to our patients, staff and Trust Board, that we are continuously reviewing patient outcomes and learning from these, the policy has been developed to ensure that a consistent approach is taken in relation to the methodology used for all Mortality Reviews and to define the assurance mechanism for mortality review in our Trust. 3 Definitions Mortality for the purpose of M&M meetings, mortality relates to any deaths within 30 days of procedure within a surgical specialty or any in hospital unexpected death for non-surgical specialties. Morbidity relates to adverse outcomes Complication an additional problem that arises following a procedure, treatment or illness and is secondary to it / complicates the situation. Misadventure Any injury or adverse reaction resulting from any medical treatment. Some examples are medication errors, IV infection, surgical mistakes and postoperative septicaemia. Serious Incident Requiring Investigation (SIRI) An accident occurring on NHS premises that resulted in serious injury, and or permanent harm, unexpected or avoidable death Avoidable/Preventable These terms are used interchangeably in the NHS and for the purpose of this policy preventable or unpreventable will be used with reference to whether anything could have been done to change the outcome. Page 4 of 22

5 Mortality & Morbidity Meetings (M&Ms) M&M meeting is where a multi-disciplinary group review and discuss clinical cases, outcome data (clinician and patient reported) and related information (e.g. SIRI, complaints, and any other benchmarking data). For the purpose of this policy this includes Radiology Discrepancy Meetings. M&M meetings May be joint M&M/Audit meetings as audit plays an important part in the M&M process. If separate meetings, there will need to be an agreed process for ensuring the findings from both are shared across and any actions suitable co-ordinated 4 Scope This policy applies to all clinical staff in our Trust. The implementation of this policy should be supported by administrative staff and managers as applicable. 5 Purpose The aim of this policy is to ensure: 5.1 A consistency of approach to the review of patient mortality within the Isle of Wight NHS Trust; and for that approach to be multi-disciplinary as appropriate 5.2 The outputs of any such reviews are clearly documents, and reviewed by the Mortality Review Group and reported throughout Trust governance committees 5.3 Appropriate action is taken to investigate any seemingly unacceptable mortality data 5.4 Appropriate action plans are produced and monitored in the event of any identified mortality issues 5.5 Oversee any wider system learning that comes from reviews 6 Roles and Responsibilities The Executive Medical Director is responsible for: Is responsible for ensuring the implementation of the Mortality review process and for developing an overarching framework for our Trust Board. Regularly updating the Mortality Policy to reflect any new developments. Reviewing external mortality data sources and coordinating investigation into any issues unexplained by routine processes. Coordination the weekly Mortality review meeting and monthly Mortality review group. Page 5 of 22

6 The Patient Safety, Experience and Clinical Effectiveness (SEE) Directorate is responsible for: Will hold day to day operational responsibility for ensuring the appropriate application of this policy and processing of the results of local Mortality groups Overseeing the corporate learning from Mortality meetings and providing assurance to Quality and quality governance committee in relation to the Mortality process. Clinical Directors are responsible for: Supporting appropriate multi-disciplinary M&M meetings taking place in all relevant specialities and for holding a list of Mortality and Morbidity meetings within their clinical directorate. In some cases it may be necessary for mortality reviews to be undertaken at an individual level. Establishing a reporting process from Mortality meetings to the clinical directorate Quality, Patient Safety and Risk Meetings. These will then be escalated to the Mortality Review Group. Clinical Leads are responsible for: Ensuring appropriate multi-disciplinary M & M meetings take place in their speciality Identifying an M & M chair. Liaising with the Directorate Management Team to identify relevant administrative support M & M (Audit) Chairs are responsible for ensuring: The appropriate attendance by all relevant disciplines and professional groups. For doctors in training it is a curricular requirement to attend those meetings and actively contribute to them. Monitoring attendance of staff at M & M meetings through maintenance of attendance registers. Relevant case note reviews are undertaken of deceased patients and recorded using agreed templates. Setting the agenda The accurate minutes are taken and archived in line with Information Governance processes. Collation of review findings, learning points and actions for improvement from each M&M meeting Ensuring that any identified Duty of Candour issues are addressed via the responsible clinician. Reporting M&M findings to Directorate Meetings. Escalating up areas of concern. Page 6 of 22

7 Medical staff are responsible for: All medical staff are required to proactively participate fully in the M&M process as appropriate, Morbidity and Mortality figures should form part of annual appraisal process where relevant. All clinical staff are expected to participate fully in all M&M meetings, including those in other trusts where applicable, that are relevant to their practice, this should be integrated in future appraisal and accreditation processes. Staff attending M&M meetings off site have a duty to report back to their local M&M lead any issues that are relevant to this Trust or to them personally. Nurses, Allied Health Professionals and other clinical staff are responsible for: All healthcare professionals should be involved in M&M reviews, as part of their clinical practice. This involvement could range from simply being aware of the outcome of such reviews insofar as they affect their area of practice, to full involvement in the production of data and implementation of recommendations. Directorate Quality and Risk Meetings are responsible for: Supporting the M&M meetings, and providing guidance where necessary for cases requiring review. Outcomes of the M&M meetings/reviews should be overseen by the Quality and Risk meetings. 7 Policy detail/course of Action 7.1 Each M&M Group should identify and confirm with the Clinical / Speciality Lead the following: Chairman Terms of reference Frequency of meetings, ideally should be monthly Membership (multi-disciplinary and multi-professional) Working arrangements of specialty M&M groups and frequency of joint meetings if applicable Reporting arrangements with other Quality / audit groups within the Trust. Arrangements for minutes / notation Mortality inclusion/exclusion criteria for routine patient case note review Morbidity (e.g. complications and misadventures) inclusion/exclusion criteria for routine patient case note review. Mortality Review Template to be used Completion of M&M review templates and collation of finding, learning points and actions from each meeting Storage and retrieval of minutes in line with Information Governance Policies Reporting arrangements including the escalation of concerns to the Executive Medical Director, these will be reviewed at a Quarterly Mortality Review Meeting Page 7 of 22

8 7.2 The following data should be reviewed: Where applicable e.g. Maternity, Paediatrics, Mental Health, Surgery and Orthopaedics All in-hospital deaths, in Medicine sampling may be more relevant. All in-hospital complications, misadventures as identified via the clinician or Datix reporting system Other data relating to mortality and morbidity including complaints, incidents and other benchmarking data Reviewing this data on a monthly basis will enable the areas to identify the number of cases to be reviewed each month i.e. review the Dr Foster data to identify outliers and SHMI to trigger series reviews. 7.3 The following cases should be reviewed individually: All deaths in electively admitted patients (except in cancer and haematology) All deaths in Low Risk Mortality Diagnosis Groups as per Dr Foster Mortality data All paediatric, neonatal and maternal deaths All other deaths as per terms of reference for each M&M meeting Emergency Department Deaths, with the exclusion of those patients who are dead on arrival (DOA) 7.4 In addition the following cases should be considered for review: Patients coded as having had a misadventure Patients coded as having had a complication which led to their death Incidents flagged via the Dr Foster custom alert process. 7.5 Other reviews to be carried out: All SIRIs relating to unexpected death/failure to recognise deteriorating patients/ unexpected complication these are expected to be identified on Datix Cases subject to inquest, where The Trust is likely to be at fault Morbidity and Mortality which has generated a significant patient or relative complaint Any other significant, unexpected morbidity, harm or significant concerns identified by any member of the mutli-disciplinary team/patient/carer, regarding patient outcomes, clinical practice or equipment. 7.6 The following should also be considered by the group: Any related feedback from inquests Any internal or external peer review of cases or benchmarking data (national registries, society of college outcome data etc.) Any other issues attendees wish to raise. 7.7 Weekly Mortality Reviews All deaths occurring in the acute Trust will be reviewed by a multidisciplinary team using a template agreed by the Trust mortality review group (See Appendix A) Concerns found at review will be escalated to the relevant clinical team and will be reviewed by the Trust Mortality review group. Responses will be received by the Page 8 of 22

9 Trust Mortality group. Output from all reviews will be reviewed by the Mortality review group. 7.8 Trust Mortality Review Group The Group will meet monthly in accordance with the Terms of Reference (Appendix B) The group will be chaired by the Medical Director or Deputy Medical Director The group will review the outputs of local M&M reviews as relevant and will receive an annual report from every active Mortality and Morbidity Group each year All deaths of patients under the care of Mental Health and Learning Difficulties triggering a review will be reviewed at the Mortality Review Group The Mortality Review Group will c o o r d i n a t e rapid reviews based on data from CQC, Dr Foster, TDA, and local monthly reviews. These will be recorded on the template attached (Appendix C). Results will be reported to QCPC at the quarterly mortality review and will be shared with relevant stakeholders including CCG. 8 Consultation This policy has been developed in conjunction with the Executive Medical Director and has been consulted on with medical staff and other stakeholders, as well as being available for all Trust staff on the intranet. 9 Training This policy will be implemented by the Clinical Directors in conjunction with the Executive Medical Director and the Patient Safety Experience and Clinical Effectiveness (SEE) Directorate, with relevant support and training provided. This Mortality and Morbidity Review Policy does not have a mandatory training requirement or any other training needs. 10 Monitoring Compliance and Effectiveness 10.1 The Executive Medical Director will oversee the monitoring of this policy Key performance indicators will be: Each speciality will hold M&M meetings, and have agreed terms of reference All areas of concern will be escalated to the Executive Medical Director. Each M&M will report annually to the Trust Mortality Review Group. 11 Links to other Organisational Documents Isle of Wight NHS Trust Information Governance/Risk Policy December 2013 Page 9 of 22

10 12 References The Mid Staffordshire NHS Foundation Trust Inquiry: Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust; January 2005 March 2009 Review into the quality of care and treatment provided by 14 hospital trusts in England: Overview Report. Professor Sir Bruce Keogh KBE 13 Appendices Appendix A Mortality Review Group Terms of Reference Appendix B Mortality Review Template Appendix C Mortality Outlier Rapid Review Appendix D Financial and Resourcing Impact Assessment Appendix E Equality Impact Assessment (EIA) Screening Tool Page 10 of 22

11 Appendix A MORTALITY REVIEW GROUP TERMS OF REFERENCE 1. MAIN PURPOSE 1.1 Involve the multidisciplinary team in a critical analysis of the systems and processes leading to an outcome of care. 1.2 Recommend improvements to processes and systems 1.3 Action these recommendations and monitor the results 2. MEMBERSHIP & QUORUM 2.1 Membership of the Group:- Executive Medical Director (Chair) Lead Clinician for Obs & Gynae Lead Clinician for Orthopaedics Lead Clinician for General Surgery Lead Clinician for Urology Lead Clinician for Care of the Elderly Lead Clinician for Anaesthetics Lead Clinician for ICU Lead Clinician for Medicine Lead Clinician for Pathology Associate Medical Director for SEE Associate Medical Director for Medical Education Clinical Coding Manager Patient Experience Lead Representative from Pharmacy Representative from Occupational Therapy Head of Nursing and Quality for Mental Health Clinical Effectiveness Lead Representative from Bereavement 2.2 In attendance Business & Projects Co-ordinator to the EMD (administrative support) Other attendees will be invited as required 2.3 Other members will nominate an appropriate deputy to attend in their absence. Page 11 of 22

12 3. FREQUENCY OF MEETINGS 3.1 Meetings are to be held monthly. 4. ATTENDANCE AT MEETINGS 4.1 It is agreed that all members should attend a minimum of 8 out of the 12 meetings per year. When the Group is discussing specific areas of risk are the responsibility of individuals outside of the Group membership, other attendees will be required to attend in order to present papers or to provide additional information in support of discussions. 5. DELEGATED AUTHORITY 5.1 The Mortality Review Group will provide assurance to the SEE Committee. 6. DUTIES AND ADMINISTRATION 6.1 It is the duty of the Group to uphold the Code of Conduct for NHS Managers, which includes the seven principles of public life (The lan Committee), namely, selflessness, integrity, objectivity, accountability, openness, honesty and leadership, and to maintain the Duty of Candour. 6.2 Furthermore, the Group will endeavour to uphold the principles and values as set out in the NHS Constitution for England, March The Group shall be supported administratively by the Business & Projects Co-ordinator to the Executive Medical Director 6.5 These Terms of Reference will be reviewed annually to ensure that the Group is carrying out its functions effectively. 7. ROLES AND RESPONSIBILITIES Involve the multidisciplinary team in a critical analysis of the systems and processes leading to an outcome of care. Recommend improvements to processes and systems Action these recommendations and monitor the results. Review outcome data (clinician and patient reported) and related information (e.g. incidents, SIRI s, complaints, and other benchmarking data). The focus on discussion will be on process and system change, with the aim of developing recommendations to prevent a similar adverse outcome in the future. The meeting is aimed at team learning and quality improvement and can therefore include staff at all levels of seniority. Action points will be noted for the next agenda and feedback will always be given to ensure that recommended changes are implemented and evaluated. Page 12 of 22

13 8. REPORTING ARRANGEMENTS 8.1 The Mortality Review Group will report directly to the SEE Committee 8.2 The following speciality mortality & morbidity groups will report directly to the Mortality Review Group: Anaesthetics & ICU Orthopaedics Surgical Obs & Gynae Paediatrics Acute Medicine Emergency Medicine (ED/Ambulance) Community Oncology Maternity/NICU 9. MONITORING COMPLIANCE WITH TERMS OF REFERENCE 9.1 These Terms of Reference will be reviewed annually to ensure that the Group is carrying out its functions effectively. Page 13 of 22

14 Appendix B MORTALITY REVIEW TEMPLATE CBU: Speciality: Place of death: Pt ID: DOB: Pt age: Date of admission: Date of death: Date of review: Was this admission a readmission within 30 days? Y/N Consultant at time of death: Reviewer: Discussed with coroner? Y/N/don t know PM done? Y/N/ don t know Inquest? Y/N/ don t know Main diagnosis on admission (first 24 hrs) Confirmed diagnosis (after tests, within first 5 days) Cause of death (use PM data if available) Ia Ib Ic II Have the notes been coded YES /NO /t coded yet Coding inaccuracies either in demographics, type of admission, diagnosis, procedures PART 1. These are questions about your impression of the care given based on information in notes. Please state reason if these questions are N/A (e.g. died quickly in A&E): Were the notes complete enough for you to make an assessment of the patient s journey and care they received? YES NO N/A Was death likely or anticipated at admission either due to acute condition or underlying frailties? YES NO N/A Was death likely due to a condition that was fully diagnosed during their admission? YES NO N/A Was the person reviewed regularly enough? YES NO N/A Were all episodes of deterioration adequately escalated? YES NO N/A Was there anything to suggest that diagnostic investigations were delayed or unavailable and it affected YES NO N/A the quality of the person s care or the clinical outcome? Please include out of hours. Examples include MRI, OGD, CT Was there anything to suggest the person did not have timely access to appropriate consultant-led YES NO N/A interventions that affected that quality of their care of the clinical outcome? Please include out of hours. Examples include angiography, radiological intervention, emergency surgery. Is there anything to suggest iatrogenic illness or injury during the inpatient stay YES NO N/A If surgery occurred, was death directly related to the surgery? YES NO N/A After initial review of notes, are you confident that the care was of an acceptable standard? YES NO N/A Page 14 of 22

15 PART 2. This section asks more detailed questions that are less about your clinical impression and are related to relevant audit standards: Was the person seen and thoroughly assessed by a suitable consultant within 14 hours of arrival at hospital? YES NO N/A Unable to tell While on AMU, SAU, ICU and other high dependency areas, was the person seen and reviewed by a consultant YES NO N/A Unable to tell twice daily, While on a general ward was the person reviewed at least once every 24 hours, seven days a week, unless it had been determined that this would not affect their care pathway? If needed, did the person have scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology? with reporting available seven days a week?: Within 1 hour for critical patients Within 12 hours for urgent patients Within 24 hours for non-urgent patients If needed, did the person have timely 24 hour access, seven days a week, to consultant-directed interventions sourced either on-site or through formally agreed networked arrangements with clear protocols, such as: Critical care Interventional radiology Interventional endoscopy Emergency general surgery If the person had been assessed/identified as having palliative care need pre-admission, is your impression from the notes that alternatives to hospital admission might have been more appropriate? (If yes please explain what these were in part 5) PART 3. Using your answers from Part 1 and 2, please circle the appropriate mortality outcome. YES NO N/A Unable to tell YES NO N/A Unable to tell YES NO N/A Unable to tell YES NO N/A Unable to tell Death expected refers to whether we expected them to die and/or recognised that they were at high risk of death in the days leading up to death, even if it had not been expected at admission. Optimal care broadly means that they were regularly reviewed by a senior clinician, there were no delays in investigation or treatment, that care was adequately escalated and that they did not suffer any iatrogenic illness or injury. Death expected Death not expected Optimal medical care 1 2 Suboptimal clinical care 3 4 PART 4. If death was unexpected, tick here and go on to part 5. Complete for all expected deaths, even if it was not anticipated on admission. Was CPR and the escalation plan discussed and documented with either person or relatives? YES NO N/A Was the preferred place of death identified? YES NO N/A Was it recognised that the person was actually dying in the hours or days before death? YES NO N/A Had active treatment with the intent to cure stopped and symptom control becomes the focus? YES NO N/A Was the responsible consultant involved in that decision? YES NO N/A Was the Priorities of care plan (PCP) used while they were dying? (if they died within 48 hrs of active treatment stopping please circle N/A ) YES NO N/A Once it was recognised they were dying, was the person reviewed every 24 hours as per national YES NO N/A guidance (regardless of whether they were on PCP, does not have to be by consultant) If they were symptomatic while dying, were they seen by the palliative care team? YES NO N/A While dying was consideration given to artificial hydration and nutrition YES NO N/A PART 5. Bearing in mind your responses so far, please complete the following section re next steps. further action required, other than routine feedback to M&M meeting, tick if applies: OR Further action required: Follow-up PM or inquest outcome Ask responsible consultant or other relevant staff to comment on certain issues, please list who and what those issues are: Tick if requested Date when completed Other issues, please specify: Page 15 of 22

16 Mortality Outlier Rapid Review Appendix C Issue Identified: Review undertaken by: Date: Method: Results Overview: Breakdown: 1. Coding Error 2. Coding correct, but coincidental to case of death 3. Coding correct, was not primary cause of death but part of demise 4. Coding was correct cause of death Extended case review requested number of cases Page 16 of 22

17 Overview of each case: Further Issues for review: Insert Spreadsheet Report forwarded to: Page 17 of 22

18 Appendix D Financial and Resourcing Impact Assessment on Policy Implementation NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact. Document title Totals WTE Recurring n Recurring Manpower Costs Training Staff Equipment & Provision of resources Summary of Impact: Risk Management Issues: Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? YES Are there any reported equality issues? NO If YES please specify: Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring n-recurring Operational running costs Totals: Staff Training Impact Recurring n-recurring Totals: Version 2.1 Page 18 of 22

19 Equipment and Provision of Resources Recurring * n-recurring * Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences Medical equipment Stationery / publicity Travel costs Utilities e.g. telephones Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Version 2.1 Page 19 of 22

20 Appendix E Equality Impact Assessment (EIA) Screening Tool Document Title: Purpose of document Target Audience A consistency of approach to the review of patient mortality within the Isle of Wight NHS Trust Medical Staff Person or Committee undertaken the Equality Impact Assessment Mortality Review Group 1. To be completed and attached to all procedural/policy documents created within individual services. 2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required. Positive Impact Negative Impact Reasons Gender Men Women Asian or Asian British People Race Black or Black British People Chinese people People of Mixed Race Version 2.1 Page 20 of 22

21 White people (including Irish people) People with Physical Disabilities, Learning Disabilities or Mental Health Issues Sexual Orientat ion Age Transgender Lesbian, Gay men and bisexual Children 0-18 Older People (60+) Younger People (18 to 24 yrs.) Faith Group Pregnancy & Maternity Equal Opportunities and/or improved relations tes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact: Legal (it is not discriminatory under anti-discriminatory law) YES NO Intended If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. Version 2.1 Page 21 of 22

22 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below: 3.2 Could you improve the strategy, function or policy positive impact? Explain how below: 3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or improves relations could it be adapted so it does? How? If not why not? Scheduled for Full Impact Assessment Name of persons/group completing the full assessment. Date Initial Screening completed Date: Version 2.1 Page 22 of 22