Patient safety incident response plan
Author(s)
Lesley Munshi, Associate Director of Patient Safety
Natalie Cook, Strategic Project Lead
17/08/2023
Reviewer
Dawn Jessop, Deputy Chief Nurse
Rachel Weddle, Associate Director of Patient Safety
30/11/2023
Authoriser
Jenna Wall, Director of Nursing and Midwifery, North East and North Cumbria Integrated Care Board
Kirstie Hesketh, Assistant Director of Quality and Patient Safety, North East and North Cumbria Integrated Care Board
4/12/2023
1. Introduction
1.1 The patient safety incident response framework (PSIRF) is a different and exciting approach to how we respond to patient safety incidents. This is not a change which involves us doing the same thing but calling it something different, it is a cultural and system shift in our thinking and response to patient safety incidents and how we work to minimise recurrence. PSIRF enables us to move away from investigating incidents to produce a report to meet specific criteria in a framework, instead, our focus will be patient safety incident responses that will support learning and improvement.
1.2 This patient safety incident response plan (PSIRP) sets out how Tees Esk, and Wear Valleys (TEWV) NHS Foundation Trust will seek to respond to and learn from patient safety incidents reported by staff and patients, their families, and carers as part of our work to continually improve the quality and safety of care we provide over the next 12-18 months.
1.3 This plan is dynamic in that we will remain flexible and consider the specific circumstances in which patient safety issues and incidents occur, including associated learning and the needs of those affected. The plan will also help us measurably improve the efficacy of all our local reviews, as well as patient safety incident investigations (PSIIs) as detailed below in the National and Local priorities sections.
1.4 The plan will be underpinned by a new Patient Safety Incident Response Framework PSRF Policy.
1.5 A glossary of terms used within this document can be found in appendix 4.
2. Our services
2.1 Tees, Esk, and Wear Valleys NHS foundation trust (TEWV) was formed in April 2006 and was authorised as a foundation trust on 1 July 2008. From education and prevention to crisis and specialist care our talented and compassionate teams work in partnership with our patients, communities, and partners to help the people of our region feel safe, listened to, understood, believed in, and cared for.
2.2 We provide mental health and learning disability services for the people of County Durham and Darlington, Teesside, North Yorkshire, York, and Selby. Based on April 2022 figures, the unweighted population we serve is 2,120,347.00. We currently have 705 in-patient beds based in 15 hospitals (July 2023). We employ over 7,500 staff who work across more than 90 sites.
2.3 The Trust is commissioned to provide the following services:
- Adult mental health (inpatient and community including mental health crisis, services for the deaf, Psychiatric Intensive Care Units, acute in-patients, Liaison Psychiatry based in acute Trusts, perinatal mental Health Services)
- Mental health services for older people in-patient and community – (including memory clinics)Adult learning disability (in-patient and community)
- Adult medium and low secure services (including mental health, learning disability and autism spectrum disorder)Rehabilitation services
- In-reach into prisons (North-West, North-East, Hull and Humber)
- North-East immigration removal centre
- Liaison and Diversion services
- Adult eating disorders (in-patient and community)
- Child and Adolescent mental health services for forensics, respite, and community services
- Talking Therapy Services
2.4 A full directory of the services we provide as well as contact details can be located on the TEWV website. We deliver our services through two care groups, which are supported by corporate services. These care groups are:
- Durham, Tees Valley, and Forensics (DTVF)
- North Yorkshire, York, and Selby (NYY&S)
2.5 The trust has a discreet team of experienced serious incident reviewers which sits within the patient safety team. This team is the engine room, working in conjunction with the Care Groups, for monitoring all patient safety events from no harm to catastrophic harm, providing assurance on the quality of incident reporting, correct categorisations, quality, and timeliness of early learning reviews as well as the identification of themes and monitoring of associated actions.
2.6 Everything we do in TEWV is guided by ‘Our Journey to Change’ and our trust values. Our Journey to Change, sets out where we want to be and how we will get there. It was shaped by Our Big Conversation which involved 2,500 colleagues, service users, families, carers, partners, and our local communities. We are committed to three big goals over the next 5 years, these are to co-create a great experience for our patients, carers, and families, to co-create a great experience for our colleagues and to be a great partner. We are also working hard to embed our values and make sure that everyone, in every role across the organisation demonstrates Respect, Compassion and Responsibility. Our Journey to Change inspires all actions and decisions we make at all levels, all the time! In keeping with Our Journey to Change, we have working towards our 3 goals by ensuring that people using our services, families and carers, staff and partners have been involved in defining our patient safety incident profile and patient safety improvement profile prior to transitioning to PSIRF in January 2024.
3. Defining our patient safety incident profile
3.1 TEWV has a continuous commitment to learning from patient safety events. We have developed our understanding and insights into patient safety over the last 3 years to help us understand the trusts priorities for 2023/2024. We have engaged with key stakeholders, both internal and external and undertaken a review of data from various sources to define our patient safety incident profile. These sources include findings from external reviews, internal serious incident reviews, structured judgement reviews, inquests, complaints, patient/carer experience, staff surveys, safeguarding reviews, our organisational learning group, our fundamental standards group, the National Confidential Inquiry Suicides Homicides (NCISH) annual report, the Ockenden and Kirkup reviews, media reports from Panaroma (Edenfield) and Dispatches, as well as learning identified through shared forums and collaboratives with other trusts within the North East region.
3.2 We nurture the recovery journey of anyone in need of our help. In our Trust, everyone has a say in how they are supported and treated because we listen to every person in our care until they feel understood. Our patients, their families and carers work together with us towards better mental health and well-being.
3.3 TEWV commenced planning for PSIRF well in advance of the release of documents in August 2022. We consulted with PSIRF early adopters and continue to work closely with our neighbouring NHS Trust.
3.4 National standards related to PSIRF require a different approach to the oversight of patient safety events, with a focus on improved involvement of families, carers, and staff.
3.5 We have taken the following proactive actions to help us transition smoothly to PSIRF:
- In March 2020 we held a conference for families bereaved by suicide. This collaborative approach to incident investigation and associated learning provided us with feedback from families of their experience of being involved in an incident investigation by the Trust. This work enabled us to identify opportunities for improvement. Outcomes included the appointment of a Family Liaison Officer (FLO) and a further deep dive event. The deep dive event took place in July 2021 this resulted in further actions including mapping of the human experience of families and staff to the existing incident process to inform improvement work.
- In January 2021, the trust initiated key improvement work focusing on patient documentation, recognising that high quality documentation is an enabler of high-quality patient care. To monitor compliance with key standards, a Quality Assurance Schedule was developed. The Quality Assurance Schedule was implemented in the Trust from 01 April 2021 and uses 7 different assurance tools across in-patient and community services. Since inception, the tools have been developed to reflect and provide assurance that improvements are being made in relation to overarching themes identified from actionable learning relating to patient safety events.
- From May 2021 to December 2022 preparatory work was undertaken to ensure that effective procedures and processes were in place for identifying and reporting, correctly classifying, reviewing, and managing patient safety incidents, reviewing systems and processes to identify learning, identification of common themes, compliance with the duty of candour and the extent of family involvement following patient safety incidents. Outputs were shared with TEWV staff. Revised templates were devised to help with the transition to PSIRF capturing learning from moderate patient safety related incidents, compliance with the duty of candour and timely responses to early learning and themes. 80 people attended the event. Participants included bereaved families, all grades, and disciplines of clinical/medical/AHP staff, senior members of the board including the chief executive, director of nursing and quality, commissioners, provider collaboratives and representatives from NHSE.
3.6 In July 2022 we undertook a thematic review of 140 patient safety incidents from a 3-year-period across all services and specialities. This review included cases that had been investigated as either a serious incident or a structured case review under the mortality review process. In relation to cases investigated as a serious incident, seven overarching themes were identified. We triangulated this data with learning from mortality reviews, moderate harm incidents, external reviews, and complaints; the overarching themes applied to all learning identified. These themes were as follows:
- Risk assessment, risk management and contingency planning
- Safeguarding
- Medication Management
- Patient, carer, relative involvement
- Multi-agency involvement
- Care planning
- Record keeping
3.7 Each overarching theme was further analysed to help identify local priorities for patient safety and areas of learning (see local priorities).
4. Defining our patient safety improvement plan
4.1 In February 2021, an organisational learning group, chaired by the Director of Quality Governance was established to strengthen and embed the trusts arrangements in relation to responding effectively to learning from a range of sources.
4.2 In 2022, a Strategic Fundamental standards group, chaired by the Chief Nurse, was established. This provides an opportunity for both care groups and corporate services to consider trust-wide learning from patient safety events and how learning can be incorporated into clinical practice, policy, and procedures.
4.3 In October 2022, a listening and engagement exercise related to the Trust’s Patient Safety Incident Management (PSIM) pathway was commissioned by the Director of Nursing and Governance and the Director of Quality Assurance. The aim was to identify gaps in the existing PSIM pathway prior to transitioning to PSIRF. Methods for the listening exercise included quantitative and qualitative approaches involving 91 staff, including seven categories of staff groups, through three virtual meetings and 11 face to face focus groups. This was in addition to the provision of an online questionnaire for staff in selected areas who were unable to attend the listening exercise.
4.4 The following overarching issues were identified:
- A cumbersome IT infrastructure which required review to support changes to the PSIM pathway going forward
- A de-skilled workforce due to centralised PSIM systems and processes
- A lack of robust training to prepare staff for change
- A lack of robust governance/response to escalated safety risks
- A lack of communication and/or opportunities to learn from incidents due to insufficient resources
- Improved engagement with families was required
4.5 The following points were identified as key determinants for success:
- A visible, collaborative, executive team with strong leadership from both corporate and care groups to communicate the change programme
- Programme management resources to support both national and local PSIM changes across the organisation
- A clearly defined governance structure that would facilitate key implementation roles for a coordinated and effective change management process
- A well-informed phased implementation plan that reflected the experience of staff closest to the safety issues, supported by ongoing progress updates
- The engagement and involvement of a wide range of staff and roles to harness their expressed enthusiasm to drive change
- A positive organisational culture that would support and incentivise staff autonomy to engage in continuous improvement
4.6 Our Journey to Change set out a five-year strategy that included five areas of focus: Clinical, Quality, Cocreation, People and Infrastructure. As part of this journey, immediate priorities within the Clinical Journey and the Quality Journey were identified. As there were clear interdependencies between the priorities within both Journeys, taking into consideration the key determinant for success, it was agreed that these would be managed under one transformation group, the Advancing Our Clinical, Quality & Safety Journey to Change (AOCQSJ) sub-portfolio Board. The AOCQSJ currently oversees existing structures that are responsible for the delivery of the clinical, quality and safety priorities.
4.7 The Patient Safety Incident Management (PSIM) Board reports into the AOCQSJ. The purpose of the PSIM Programme Board is to be the primary decision-making body for the programme of work to transform patient safety incident management processes in TEWV. This includes the national transformation towards the requirement of the Patient Safety Incident Response Framework. The delivery of the transformation programme involves four projects that are coordinated by two Project Steering Groups, which report into the PSIM Board.
4.8 The four projects are as follows:
- PSIRF to embed the PSIRF framework and develop a patient safety incident response plan and policy
- LFPSE (Learning From Patient Safety Incidents) to switch from NRLS (and later STEIS) to LFPSE and to have a full understanding of the functions within LFPSE and how this can be used to support on-going learning
- Incident Reporting to clear the backlog of patient safety incidents to enable a smoother transition to the new PSIRF
- Risk Management/Datix re-procurement to have a LFPSE compliant risk management system that facilitates the new patient safety events and other risk processes that provides sustained monitoring and reporting
4.9 The Programme Board has provided direction, resources and support to the Project Steering Groups which will escalate issues, risks, and decisions that they cannot deal with themselves. The two project steering groups are as follows:
- Risk Management System Group
- Policy and Process Group
4.10 Duty of Candour
4.10.1 Further to both internal identification of gaps and weaknesses, findings, and recommendations from external reviews by the Care Quality Commission (December 2021), Niche (March 2023) and AuditOne (April 2023), TEWV recognised there was significant improvement work required to ensure Duty of Candour is fulfilled. Duty of Candour is included in the scope of the Quality Journey. To support the improvement work TEWV commissioned NECS to complete a short Duty of Candour review project from January to April 2023.
4.10.2 The scope of the NECS review project was to:
- Review the Trusts current Duty of Candour policy against best practice and provide a revised draft policy
- Governance and Compliance – to design and implement a robust duty of candour reporting process
- Improve awareness and understanding
- Training and development
4.10.3 Recommendations included:
- To develop and implement a revised duty of candour policy
- Governance and Compliance – to design and implement a robust duty of candour reporting process
- Improve awareness and understanding
- Training and development
4.10.4 The policy has been since been revised and further improvement work continues.
4.10.5 Further information about our improvement programmes for 2023/24 can be found in appendix 1.
4.11 Transition to PSIRF
4.11.1 Due to the incremental changes the Trust has made over the last 2 years we will be able to transition to PSIRF in January 2024. Prior to the transition, several processes have been reviewed and functional flowcharts created to align to other interdependent governance streams such as mortality reviews and the patient safety team processes. Several engagement workshops have been undertaken and webinars are planned to update staff members on how PSIRF will impact on their roles within clinical services. The PSIM group are working alongside the communications team to ensure that information about the transition is disseminated trust wide. This policy and process group continue to work with clinical services and an away day has already been held with matrons, practice development practitioners and Speciality Development Managers.
4.11.2 In terms of training, the substantive patient safety team, who will be carrying out the PSIIs, have either received bespoke training from a recognised training establishment or have attended the training provided by HSIB. New staff joining the PST will receive training compliant with PSIRF as soon as practicable. A budget has been determined for additional training for clinical staff who will be completing early learning reviews and other tools from the PSIRF toolkit.
4.11.3 From 1st October all PSIIs being commenced will be written on the PSIRF templates. Further discussions will be required with Coroners, as not all incidents will require a full comprehensive Patient Safety Incident Investigation and reports will be presented in a different format. There is a new PSIRF Policy, that will be in place for January 2024.The Trust has ensured that the National Patient Safety Strategy training levels 1 and 2 have been made essential for all staff.
5 Our patient safety incident response plan: national requirements
5.1 Given that the Trust has definable resources for patient safety incident response, we intend to use those resources to maximise improvement. PSIRF allows us to do this, rather than repeatedly responding to patient safety incidents based on subjective thresholds and definitions of harm, from which new learning will be limited.
5.2 Some patient safety incidents, such as Never Events and deaths thought to be more likely than not due to problems in care will always require a Patient Safety Incident investigation (PSII) to learn and improve. For other types of incidents which may affect certain groups of our patients, a PSII will also be required. These have been determined nationally, but the Trust fully endorses this approach as it fits with our aim to learn and improve within a just and restorative culture.
5.3 As well as PSII, some incident types require specific reporting and/or review processes to be followed.
5.4 For clarity, all types of incidents that have been nationally defined as requiring as specific response will be reviewed according to the suggested methods and are detailed in the table.
View our patient safety incident response plan: national requirements (table)
6 Our patient safety incident response plan: local focus
6.1 These themes will have ongoing review, in order to remain flexible and consider improvement planning as required where a risk or patient safety issue emerges from our own ongoing internal or external insights (see appendix 2):
- TEWV is implementing quarterly MDT thematic reviews of serious incident actions. (First meeting was 04/11/23) This meeting consists of Medical Director, Chief Nurse, Director of Therapies, Deputy Chief Nurse, Associate Director of Patient Safety, Associate Director of Quality Governance, Compliance and Quality Data. Complaints and HR. The meeting reviews and establishes thematic information and allocates to specific workstreams or identifies new systemic actionable learning. The ongoing feedback and learning will then be aligned to QA processes, audit etc as identified.
- All workstreams that are identified are monitored through the Organisational Learning Group, Quality Governance, Compliance and Quality Data team and learning is disseminated through the trust ‘fundamental Standards group.’ As well as all other forums of information sharing, monitoring and scrutiny.
6.2 All moderate and above incidents will be reviewed by the patient safety team huddle in order to ensure oversight and support identification of tools to be used, organisational learning and accurate site level monitoring of incidents. For any incident not meeting the PSII criteria, or any other incident, we will use a specific patient safety review tool to enable a learning response. For lesser harm incidents we propose to manage these at a local level with ongoing thematic analysis via our existing Trust assurance processes which may lead to new or supplement existing improvement work. InPhase will allow incidents to be reported thematically and this will be run on a monthly basis through patient safety huddle. Appendix 3 demonstrates the patient safety processes and how learning will be implemented.
View our patient safety incident response plan: local focus (table)
6.3 PSIRF allows organisations to explore patient safety incidents relevant to their context and the populations served. From the work we have undertaken in defining our Quality Journey and patient safety incident profile TEWV have identified these 10 patient safety priorities as local focus. The priorities identified reflect the various services we provide and the population we serve. This will allow us to apply a systems-based approach to learning from all incidents relating to these priorities, exploring multiple interacting contributory factors within established resources.
