* Please provide a brief outline of your work.
The Patient Safety Team (PST) started embedding Learning from Excellence (LFE) into the culture of the organisation, focusing on positive reporting. We created an innovative way of staff engagement, called “Risk Roadshows” where PST go to wards/areas and discuss Incident reporting, LFE, Risk Registers and Duty of Candour.
This was created in times of limited clinical staffing with high vacancy rates. Risk Roadshows feed into our Kitchen Table Event, colleagues utilise this event to learn from Serious Incident’s e.g. sepsis/falls. We developed Divisional Safety Huddles to triangulate Incident reporting, Claims, Complaints, Inquests ensuring rapid reviews/actions are completed.
* Please describe the actions you took to achieve your result.
LFE was acknowledged as a way of recognising staff’s good practice which can be shared with other colleagues. We use Right Cause Analysis using the same methodology as Root Cause Analysis where we use timelines to pinpoint where things went right and why they went right.
We are using Safety 1 techniques to move into a safety 2 culture. We use Safeguard system to capture and record LFE nominations from staff using the safety 2 approach instead of safety 1 which is incident reporting.
The innovation is that we scoring the nominations using A, B and C.
A- Right Cause Analysis, B- Local Learning, C- formal acknowledgement.
We presented this new approach in partnership with one of the main supporters of LFE, the Clinical Director of General Surgery, to the Consultant’s Conference.
Risk roadshows were developed to share topics including; LFE, DOC, Risk Registers, Incident reporting, focusing on 1-1 discussions with staff on wards. We use the roadshows to embed good practice in relation to patient safety, which we has succeeded and has been recognised by CQC in their latest report.
The Divisional Safety Huddles triangulate from different sources, the issues that the Division faces and ways in which they can move forward and learn from them. These sources include Complaints, Clinical Claims, Inquests and Incidents. The huddles were created in order to validate moderate and above incidents with clinical input on a weekly basis to ensure that incidents were being reviewed and acted on. An agenda is set which outlines the different issues the Division need to act upon including timely compliance with DOC timescales.
* Please list the most significant results
122 excellence nominations reported for LFE from 01/07/2017 to 09/02/2018. Of the grading’s so far we have 4 A’s, 20 B’s and 86 C’s. We have undertaken three roadshows so far since they were created so we have spoken to over 1,200 members of staff about their understanding of DOC, Incidents, risks and most recently Learning from Excellence. We have engaged with over 200 staff through our Kitchen Table Events.
Since the implementation of the Divisional Safety huddles there has been a significant decrease in the number of incidents awaiting manager sign off.
* Describe how your project has spread to other teams, departments or organisations
The Divisional huddles were replicated by all Divisions in the Trust to ensure consistency of approach. LFE is something every team can participate in through the excellence nomination process. We have shared our learning from LFE and DoC with NHS Improvement at the Patient Safety Conference.
As part of our Serious Incident investigations we have introduced family liasion roles within the DoC process, where we look to provide families with regular updates in relation to the progress of the investigation. Risk Roadshows have led to staff feeling engaged and supported in DoC, incident reporting, Coroner’s Inquest’s and risk management.