Prior to 2017, the Trust had been identified in a CQC report as having low incident reporting rates. Staff reported that they were not getting sufficient feedback as to what had happened in response to an incident. There were also reports of staff not feeling supported following an incident. Investigation times tended to be slow. Patients sometimes reported not feeling involved in investigations or being disappointed their views were not included in incident investigation reports.
The UHCW Patient Safety and Risk Team assessed the problems and set about addressing them. We used the Rapid Process Improvement methodology and PDSA cycles to address these problems. Over the course of 2017 we did the following:
- Complete re-design of the incident reporting and investigation form to be quicker and more logical for clinical staff- Development of electronic safety dashboards for all areas to ensure safety information is easily accessed by clinical teams
- Introduction of daily multidisciplinary Patient Safety Huddles in all clinical areas of the Trust (80+)
- Introduction of the Patient Safety Response Team, a daily meeting and multidisciplinary rapid response for incidents causing serious harm where the ward/department is attended by the Trust’s most senior clinicians to ensure patients are safe, staff are supported and duty of candour has commenced
- Supported numerous other teams (eg Complaints) to enhance the quality of their processes
- Developed a Learning Team methodology for better staff engagement and better recommendations following serious incidents
- Improved the Duty of Candour processes, getting patients involved in investigations and including their questions and evidence from the outset, with development of a patient leaflet
- Undertook a project to ‘triangulate’ data between claims, complaints and incidents
- Implemented a Human Factors Programme in three large, high-risk clinical areas
- Implementation of new (almost) jargon free risk training course for managers
- Development of an RCA e-Learning package
- Cleared backlogs of incident investigations, RCAs and SI actions
The implementation of these large scale changes has been led by our team of ten individuals during 2017. They have done this work despite at times carrying numerous vacancies. All of the above pieces of work have been a resounding success. Not that we got it exactly right the first time, but by making small improvements and scaling the processes up once they were successful.
The team has a strong ethos of supporting clinical staff and ensuring real and lasting change. The changes would not have been possible without commitment and discipline. None of these projects had any significant cost, apart from promotional materials for the launch of the new incident processes which cost approximately £1800.
The main resource used was the expertise of our team. We made the most of the existing staff skills, knowledge and backgrounds in clinical care, human factors, incident investigation techniques, administrative processes, relationship building and influencing.
- Incident reporting rate increased 31 to 44 incidents /thousand bed days, in top 25% nationally
- National staff survey improvements in: Feeling secure raising concerns, Treating me fairly, Giving feedback
- Reduced proportion of harmful incidents from 19.2% to 15.9%
- Reduced falls causing serious harm from average of 5 per month to 1.5
- Reduction from over ten, to zero overdue SI’s by December 2017
- Positive feedback from patients eg: “We were kept up to date. The lead nurse was wonderful. She was very caring and gave us a leaflet and told us everything.”
The new processes were developed in Critical Care, then spread to five areas, then trust wide. There was very little cost, and there has been no significant impact on staff time. We have been inundated with queries from other Patient Safety Teams and we have been holding seminars and ‘shadowing’ experiences to share our work with other trusts from across the country.
Nearby trusts have asked to utilise our new reporting form, and since we have been sharing our progress many other trusts nationally have said they plan to implement safety huddles, the Patient Safety Response process and learning teams.