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Published 30 April 2018
With learning from incidents being seen as the key to safer care, the government, CQC and NHS Improvement are currently channelling a lot of energy into how the quality of patient safety investigations can be improved.
The latest development is a plan to revise the existing Serious Incident Framework by the end of this year.
In this briefing, we look at the changes being suggested and how you can have your say on what goes into the new framework.
The patient safety team at NHS Improvement (NHSI) is currently inviting views - via an online survey - on how the national Serious Incident Framework (issued in 2015) could be changed for the better.
To accompany the survey, NHSI has produced a discussion document - The future of NHS patient safety investigation - which focuses on 5 key factors contributing to poor investigations:
The real challenge is how to resolve these problems in the context of a system under pressure from all sides and with finite resources.
One of the keys to this, NHSI suggests, may be to address the 'investigation fatigue' which arises from having to investigate large numbers of similar incidents again and again (often with 'weak' actions repeatedly coming out of these around reminding, reviewing, rewriting), leaving little time or energy to focus on real solutions.
Quality over quantity, it is being suggested, may be the answer. Careful consideration will however need to be given to how this squares with the statutory Duty of Candour where incidents reach the requisite harm threshold to trigger that duty.
NHSI has put forward a number of possible options/approaches in relation to each of the problem areas identified and is inviting those completing the online survey to rate the likely effectiveness of each of these from 'very effective' to 'completely ineffective', as they see fit.
Possible approaches you can 'rate' as part of the survey include:
NHSI is also asking for views on a refreshed set of principles to underpin the framework - i.e. incident investigations should be: strategic (e.g. boards focusing on quality of output/learning, not numbers), preventative (i.e. acting on identified causal factors), people-focused (i.e. patients/families/staff are active participants), expertly led (by trained investigators with support of an appropriately resourced investigation team) and collaborative (e.g. enabling information sharing/action across systems). These principles are designed to tie-in with those of the Healthcare Safety Investigation Branch, which will also have a central role in helping to spread good investigation practice.
We may even be looking at a new name for the Serious Incident Framework, with NHSI also seeking views on whether a change of name is needed to reflect a fresh approach to incident investigation.
The online survey will be open until 12 June 2018.
NHSI will then review the responses and work on revising the Serious Incident Framework over the summer, with a view to a new version of the framework being published by the end of 2018.
Our national team of healthcare regulatory lawyers has extensive experience of supporting and advising health and social care providers on a wide range of matters relating to incident investigations, including:
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