* Please describe the challenges or problems your solution set out to solve.
In response to concerns that the organisation was not learning effectively from serious incidents the Trust set up the Investigations and Learning Team in September 2016 with the following objectives:
• To improve individual, team and organisation learning from Serious Incidents
• To undertake impartial and transparent, high quality Serious Incident investigations by well-trained and supervised incident investigators
• To fully engage with, support and improve the experience of all people involved in Serious Incident investigations – service users and their families, victims of incidents and their families, and staff
• Look after the psychological wellbeing of investigators and administrative staff in the team
* Please describe the actions you took to achieve your result.
The initiative was undertaken to address board-level concerns about the quality of Serious Incident investigations and that as a result effective learning was not taking place representing a patient safety and staff safety risk. The initiative was cost-neutral but added significant value: the Trust conducted a survey of staff who previously completed Serious Incident investigations and identified the time and resource taken to produce (unsatisfactory) investigation reports and transferred the equivalent resource from operational services to create a central team whose sole focus is high quality Serious Incident investigations.
The team was established in September 2016 and undertakes all Trust Serious Incident investigations. All investigators undertook Post-Graduate (Masters Level) Certificate in Serious Incident Investigation at University of Central Lancashire to improve their knowledge and skills. Service users and family members who had been involved in a serious incident played a major role to helping select investigators in the recruitment process.
Two people affected by serious incidents to a family member are working with the Trust to develop storyboards to be used in staff training to improve our response to people affected by an incident. We also developed a leaflet for service users and their families explaining the Serious Incident process (see file PATIENTSAFETYAWARDS2018_QUALITYIMPROVEMENTINITIATIVE_Leaflet for Service Users and Families.pdf).
Unless otherwise requested, all service users and/or family members receive a copy of the final report in a language they can understand and meet with investigators to discuss the report and access to practical and psychological support if needed.
In order to create the conditions for an open learning culture the team developed an information leaflet for staff including a set of core beliefs and guiding principles to create a culture where staff feel safe to be honest and a Team Charter to provide information about how the team approach incident investigations (see file PATIENTSAFETYAWARDS2018_QUALITYIMPROVEMENTINITIATIVE_A New Approach to Investigating Serious Incidents.pdf). An extensive intranet site was developed for staff.
The team undertake post investigation clinical team debriefs allowing teams to discuss and reflect on the learning from incident reports and all staff involved in an investigation receive a copy of the final report. In March 2017 the team developed an online and paper feedback questionnaire which is sent to everyone involved in an investigation (service users, their families, victim of incidents, staff). The outcomes are used in supervision with investigators to improve the experience of people involved in an investigation (see outcomes).
* Please list the most significant results
Quantitive and qualitive outcomes can be found in the accompanying file PATIENTSAFETYAWARDS2018_QUALITYIMPROVEMENTINITIATIVE_Investigation and Learning Team Feedback March-October 2017) but are summarised as:
• Consistent and sustained high levels of service user and family satisfaction with their experience of the investigation and contact with their investigator.
• Consistent and sustained high levels of staff satisfaction with their experience of being involved in an investigation.
• Board-level recognition of improvements in the quality of investigations and reports
• Commissioner recognition of significant improvement
• A number of Coroners have specifically referred to the quality and honesty of reports in their closing comments at inquests
* Describe how your project has spread to other teams, departments or organisations
• A neighbouring Trust has set up a similar team and we have contributed to their staff induction
• Regular ‘Incident on a Page’ learning bulletins shared on the Trusts weekly staff briefing
• Presentations to medical induction programmes led to significant numbers of senior medical staff assisting in investigations
• Learning from investigations shared in the Trust’s ‘Quality Matters’ bulletin by Director of Nursing
• Use of Twitter has helped identify other interested organisations in order to network and share good practice
• Presentation of team’s work and outcomes at Trust Quality Improvement Conference
• Investigators attend clinical team meeting to discuss work of the team