Patient Safety Policy

Introduction

Policy Statement

This policy supports the requirements of the Patient Safety Incident Response Framework (PSIRF) and sets out Omnes Healthcare approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

The PSIRF advocates a co-ordinated and data-driven response to patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.

This policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF:

• compassionate engagement and involvement of those affected by patient safety incidents.
• application of a range of system-based approaches to learning from patient safety incidents
• considered and proportionate responses to patient safety incidents and safety issues
• supportive oversight focused on strengthening response system functioning and improvement.

Scope

This policy is specific to patient safety incident responses conducted solely for the purpose of learning and improvement across all secondary and primary care services provided by Omnes Healthcare.

Responses under this policy follow a systems-based approach. This recognises that patient safety is an emergent property of the healthcare system: that is, safety is provided by interactions between components and not from a single component. Responses do not take a ‘person-focused’ approach where the actions or inactions of people, or ‘human error,’ are stated as the cause of an incident.

There is no remit to apportion blame or determine liability, preventability, or cause of death in a response conducted for the purpose of learning and improvement. Other processes, such as claims handling, human resources investigations into employment concerns, professional standards investigations, coronial inquests, and criminal investigations, exist for that purpose. The principle aims of each of these responses differ from those of a patient safety response and are outside the scope of this policy.

Information from a patient safety response process can be shared with those leading other types of responses, but other processes should not influence the remit of a patient safety incident response.

Roles And Responsibilities

Associated Policies

This policy is to be read in conjunction with the following policies:

Policy

Our Patient Safety Culture

Omnes Healthcare puts patient safety at the heart of all the services it provides. To ensure the culture within the company is a just and supportive we work collaboratively across all disciplines. It is recognised that we deliver care as a team with patients proactively included in decision making.

Omnes Healthcare is working to improve patient participation across all services. This is to ensure the patient voices is at the centre of service development and quality improvement.

It is only by continuing to develop the open transparent no blame culture that we will continue to improve the safety of our services.

The safety of patients is important within the triangulation of transparent responses to complaints, hearing the patient voice and patient participation.

The reporting of issues and near misses is reported and discussed at monthly governance meetings. This is within a psychologically safe environment to ensure the reporting is used to learn and develop staff and services. A no blame culture has always been at the heart of patient safety at Omnes Healthcare, and this will continue.

To continue to develop a just culture the development of values and behaviours expected is communicate widely. It is also demonstrated by senior leadership and part of the everyday delivery across the whole company.

It commences at recruitment with the values-based recruitment and continues throughout employment with values-based appraisals.

A Omnes Health care moves forward with Patient Safety Incident Reporting Framework (PSIRF) we will develop the skill necessary for investigating. This will be led by including patients, family and carers who are effective. The team will ensure that questions regarding care and the incident will be answer openly and transparently.

The patients will, as aways, be at the heart of investigations. Communication of learning and improvements will continue to be a key part of the Omnes Healthcare management of incidents and quality improvement.

Incident Investigation Pathway

Engagement Pathways

Primary Care Engagement

Primary care services all participate in Patient Participation Groups (PPG’s), and we always act on feedback.

Omnes Healthcare will also be expanding ways of providing feedback to all patients to ensure we have wide participation.

Secondary Care Engagement

At present feedback within secondary care is via patent questionnaires and thematic reviews of complaints received.

Omnes Healthcare will be using Quick Response (QR) codes to encourage more responses to services we provide. Further ways to engage are being investigated and the policy will be updated as methods of communication are developed.

As we develop the incident response process further patient engagement will be undertaken the pathway below shows how the Omnes Healthcare Board will be informed and engaged in the new process.

The Integrated Care Boards (ICBs) will be involved as a partner within the investigations. It may be within secondary care that this is through the commissioned service provider. Omnes Healthcare in this instance will support the commissioned service provider.

Engaging and Involving Patients, Families and Staff Following a Patient Safety Incident

The PSIRF recognises that learning and improvement following a patient safety incident can only be achieved if supportive systems and processes are in place. It supports the development of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families, and staff). This involves working with those affected by patient safety incidents to understand and answer any questions they have in relation to the incident and signpost them to support as required.

Omnes Healthcare will include patients and carers at the beginning of the investigation. We will also work closely with other organisations we provide services for. This will ensure an open and transparent process and cohesive single response for patients

Addressing Health Inequalities

As we progress with the implementation of PSIRF we will ensure we use the data available to identify issues that unequally and unfairly negatively impact at risk groups.

As we identify these issues, we will engage patients, carers and identified support groups to ensure we hear the patient voice. To ensure we have a fair system-based approach we will ensure governance staff have access to PSIRF training.

The approach to primary care and secondary care will be appropriate to the service and patient needs.

Our Patient Safety Incident Response Plan

Our plan sets out how Omnes Healthcare intends to respond to patient safety incidents over a period of 12 to 18 months. The plan is not a permanent set of rules that cannot be changed. We will remain flexible and consider the specific circumstances in which each patient safety incident occurred and the needs of those affected, as well as the plan.

Reviewing our Patient Safety Incident Response Policy and Plan

Our patient safety incident response plan is a ‘living document’ that will be appropriately amended and updated as we use it to respond to patient safety incidents. We will review the plan every 12 to 18 months to ensure our focus remains up to date; with ongoing improvement work our patient safety incident profile is likely to change. This will also provide an opportunity to re-engage with stakeholders to discuss and agree any changes made in the previous 12 to 18 months.

Updated plans will be published on our website, replacing the previous version.

A rigorous planning exercise will be undertaken every four years and more frequently if appropriate (as agreed with our integrated care board (ICB)) to ensure efforts continue to be balanced between learning and improvement. This more in-depth review will include reviewing our response capacity, mapping our services, a wide review of organisational data (for example, patient safety incident investigation (PSII) reports, improvement plans, complaints, claims, staff survey results, inequalities data, and reporting data) and wider stakeholder engagement.

Responding to Patient Safety Incidents

Patient Safety Incident Response Planning

PSIRF supports organisations to respond to incidents and safety issues in a way that maximises learning and improvement, rather than basing responses on arbitrary and subjective definitions of harm. Beyond nationally set requirements, organisations can explore patient safety incidents relevant to their context and the populations they serve rather than only those that meet a certain defined threshold.

Resources And Training To Support Patient Safety Incident Response.

The members of the governance team will be provided with training to understand PSIRF. They will also be trained in investigation skills to undertake the necessary investigations. As Omnes Healthcare is a compact company the governance team will lead this. Growth of the company and services will impact this, and reviews of our process will be undertaken, as necessary. A minimum of annually however it may be more frequently as services are expanded and new services added to the company.

Patient Safety Incident Reporting Arrangements

Omnes Healthcare have two distinct divisions primary care and secondary care. These are both have different reporting lines for services to the Integrated Care Boards (ICB). Primary care services reporting to the commissioning ICB. Secondary care services are often provided on behalf of an NHS Trust who are the commissioner service provider. In these cases, the NHS Trust will report to the relevant ICB and Omnes Healthcare will provide support to the investigation.

An investigation in either the Omnes Healthcare governance team will oversee primary or secondary care services to ensure that we understand the issues and implement any learning. We take very seriously our commitment to patient safety and continuous quality improvement. Primary Care incidents are reported via the practice manager to Omnes Healthcare Governance team, and recorded on RADAR, and the ICB.

The practice manager and the clinical lead for the practice will oversee the investigation supported by the governance team. It will be discussed at the practice governance meeting and Omnes Healthcare governance meeting. The practice manager and clinical report are responsible to the Omnes Healthcare governance meeting for timely completion of the investigation and completion of learnings and actions. Omnes Healthcare Governance team are responsible for the sharing of learnings via the governance newsletter and information for all practice governance meetings. Secondary Care service managers will report any incidents to the governance manager and record on the RADAR system. The service manager will also inform the general manager for the service who will be responsible for the support provided to the NHS Trust during the investigation. The governance team will support the service manager whenever necessary with the investigation and reports to be submitted.

The Medical Director is the executive lead for all clinical incidents and is supported by the governance team. The Medical Director chairs the governance meeting to ensure effective oversight of investigations, learning and completion of any actions needed.

Patient Safety Incident Response Decision-Making

Omnes Healthcare process for incident reporting has three elements: - 1. Immediate incidents that are such as a never event or patient harm two. Emergent issues through audit or review three. Themes through complaints that demonstrates potential risk or harm. The ways to identify these are through review of audits and complaint themes at clinical governance and 6 monthly reviews of issues or complaints. The governance committee will agree investigations and review reports.

Responding To Cross-System Incidents/Issues

Omnes Healthcare working across systems within the services they provide. The teams ensure they work closely with all service providers. The governance team work closely with the operational team and governance teams within the providers to provide clarity and support. The lead investigator ensure delivery of the report Omnes Healthcare ensures that any learnings or safety actions arising are implemented in a timely manner. These actions and learning are monitored in line with all safety actions arising within Omnes Healthcare.

Learning from Incidents

Timeframes for Learning Responses

On completion of investigation and feedback to patients, carers, and families the learning will be shared with the company.

The feedback will first be shared with the members of the team involved in the incident. Reflection on the incident will have been part of the investigation and report process.

The learnings will then be shared via several methods: -

• Governance newsletter – next newsletter within a month
• Governance meetings for each service – next meetings within 6 weeks of learning and report sign off.
• Policy and procedures changes – within 3 months of learning and report sign off.
• Team meetings – within 6 weeks of learning and report sign off.

Safety Action Development and Monitoring Improvement

The actions from the investigation will be recorded against the incident. It will be the responsibility of the General Manager of the areas for these to be implemented. The governance team will support the implementation. The monitoring and closure of safety actions will be in primary care via the practice governance meeting. Secondary Care will provide the evidence of closure. Closure of all actions must be verified by the Omnes Healthcare governance meeting. All safety actions that are overdue will be monitored at the monthly governance meeting.

Safety Improvement Plans

Each investigation will have a plan for any safety actions identified. These will be clear, timely and clearly improve quality,

The plans will be linked to the overarching annual quality improvement plan.

Review of individual plans will identify common themes and ensure not duplication of effort or conflicting outcomes.

Training and Development

It is anticipated that the investigations will be undertaken by the governance team who will have investigator training. It will ensure equity and clarity on achieving the clarity of investigations and clarity of learning implementation.

As the services grow it will be planned to implement PSIRF leads across services and primacy care.

Complaints and Appeals

Complaints or appeals against outcomes of safety investigations will be directed to the managing director. A review of the investigation will be undertaken by an identified executive director. This review will be presented to the managing director who will decide on the way the investigation was undertaken and the findings. This will be undertaken within 30 days of receiving the complaint and written response will be provided.

Policy Information

Version History

Authorisation Details

Authorisers

Final Authorisation

Equality Impact Assessment

The purpose of this policy is to provide diversity and equality to all in implementation of the policy, irrespective of their age, disability, gender reassignment, marriage and civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation. We oppose all forms of unlawful and unfair discrimination.

All employees, whether part time, full time or temporary, will be treated fairly and equally and with respect. All employees will be helped and encouraged to develop their full potential and the talents and resources of the workforce will be fully utilised to maximise the efficiency of the organisation.

Consider the impact of the policy on the following characteristics or groups:

If any groups have been identified that may be impacted by this policy, please describe the actions taken to eliminate discrimination, harassment and victimisation, and address the impact on equalities:

Training Needs Analysis