“One of the most common issues we find is the way that organisations investigate, communicate and learn when things go wrong.” Says the CQC in their review into the quality of investigation reports.
This briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS.
It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review.
The briefing provides a summary of their findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
Five opportunities for learning:
- Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
- Patients and families should be routinely involved in investigations.
- Staff involved in the incident and investigation process should be engaged and supported.
- Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
- Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.
On learning opportunity 1, the CQC concluded that “Some of the incidents we reviewed would have benefited from alternative approaches, using less complex but more efficient ways to address the needs of the patient(s) and to identify any mitigating actions that could prevent the incidents happening again”.
Learning opportunity 2, the CQC quotes the Serious Incident Framework, saying, “the needs of those affected should be a primary concern for those involved in the response to and the investigations of serious incidents.”. They CQC went on to say that the guidance recommends that patients and families should provide the support, information and answers that they require. This report, while not being able to conclude that patients and families were not informed, it did not demonstrate expected guidance was being met. (Only 12% of the reports showed cleared evidence of the patients and families being involved).
Learning opportunity 3, the CQC stated that when serious incidents happen, it can have a profound effect on the staff that should be supported. It stated that skillful management of interviewing staff in a non-threatening and honest environment is required.
Learning opportunity 4 highlighted that only 8% of the CQC reports showed evidence of a clearly structured methodology identifying:
- the key issues to be explored and analysed
- the contributory factors and underlying systems
- the key causal factors that led to the incident
Learning opportunity 5 focused on organisations not always following guidance and so missing failures to stop re-occurrences.
This CQC report concluded that “Provider organisations have a primary responsibility for making sure their staff have the skills they need to carry out quality investigations. They should have external expertise when needed and opportunities to contribute to wider improvement initiatives when incidents may not warrant a formal investigation…..Trust boards must ask themselves if their investigations are making a difference and leading to improvement”.
The CQC called for all to come together, including the new Healthcare Safety Investigation Branch to provide, amongst other objectives:
“support to hospitals to develop the capacity that is required to encourage and embed good investigative practice into their wider approach to learning and improvement, and to make sure that patients and their families are informed and involved, in line with the Duty of Candour”
Original source: http://linkis.com/www.cqc.org.uk/conte/ianvd
Relevant events to support the CQC requirements outlined in this report:
IN HOUSE training available where we can come to your organisation: for more information email firstname.lastname@example.org
OR attend one of our regional training days:
30th September – Stevenage
18th October – Manchester
14th November – Bristol
7th December – Milton Keynes