Welcome to the first Mersey Care Patient Safety update. This is a bi-monthly update to keep you informed on patient safety, improvement work programmes happening across the Trust and sharing learning that has taken place.
Who are the Patient Safety Team?
The Patient Safety Team supports and enables the delivery of safe, quality patient care. The team creates safe systems to:
- Reduce the potential for unintended and avoidable harm
- Minimise risk to patients whilst they are receiving care
- Review with an open and transparent approach when things have not gone as planned, involving service users and their families where possible, and identify learning
- Build on good practice so that patients have the best possible experience of care
- Support staff to minimise patient safety incidents and drive improvements in safety and quality.
The team provides clinical and non clinical patient safety expertise across the organisation. The team sets policy direction and works with partner organisations like other NHS bodies, CQC and the Department of Health and Social Care (DHSC) to improve patient safety.
The team are committed to supporting a restorative just and learning culture across the organisation. This means that when something doesn’t go as planned, staff are supported to have open discussions without fear of blame, where the focus is on “what was responsible, not who is responsible”. By understanding what has happened, we can learn from incidents and improve the quality of our services.
The Patient Safety is made up of the following teams:
- Serious Incident team
- Mental Health Law Team
- Mortality and Incident Review Team
- Incident and Risk Team
- Claims and Inquest Management Team
- The Complaints Team.
The team provides clinical and non clinical patient safety expertise across the organisation. The team sets policy direction and works with partner organisations like other NHS bodies, CQC and the Department of Health and Social Care (DHSC) to improve patient safety. The team is here to support all staff.
The Trust wide Strategic Quality Improvement Group (SQIG) commenced in November 2021, this group meets Bi-monthly with a focus on the implementation of the Mersey Care learning framework. The group will support shared leaning approaches for across all divisions to be shared and embedded. All divisions can now share their current quality improvement projects using Live QI. Each update will share learning undertaken and quality improvements from across the Trust.
The MCFT lessons learned frameworks has been developed in collaboration with the Centre for Perfect Care and all representation from all divisions. It is accessible through the Patient Safety Page on Your Space. This has been established to ensure when an incident or event occurs, we identify the learning to support quality improvements and prevent serious incidents from happening again. Incidents are just one source of learning; we can learn from a wide variety of sources including: our service user and carers’ feedback; learning reviews, audits; thematic reviews and local quality improvement all of which we will work to share through our Patient Safety Matters updates.
The lessons learned framework continues to develop and supports a process and culture of identifying learning that can be shared to increase awareness, take action to reduce incidents recurring and to make quality improvements.
The development of the trustwide lessons learned framework aims to drive and systematically enable shared learning whilst ensuring staff involved in incidents are supported and psychologically safe. The learning framework will facilitate a systematic approach, reviewing processes and supporting wider lessons learned across the Trust. This will enable standardised spread of action/improvements with a clear purpose to reduce the recurrence of the same root causes in future incidents, whilst linking to thematic learning as part of the MCFT Quality Improvement strategic work and sharing of best practice.
Learning from Serious Incidents across the Trust
Each update will focus on key learning and improvement. Following an inpatient death in Clock View hospital the Trust was issued with a Regulation 28, Preventing Future Deaths from the Coroner where it identified concerns with documentations relating to the supportive observations.
In response the Local division is in the process of rolling out e-observations to all inpatient wards which includes supportive and physical observations, incorporating the NEWS2 to support the recognition, management and escalation of the deteriorating patient. To further support there is a trust wide review of the supportive observation policy currently being undertaken. The review is being led by the Centre for Perfect Care and Patient Safety with divisional representation/ subject matter experts, service users and staff side all part of the working group. The policy review will be completed by the end of June 22.
Dissemination of Learning
There is an established process in the divisions to promote dissemination of learning at team level but also on a divisional and Trust wide basis. There are a number of resources to support high quality care delivery confirmed in the complaint review and also the learning that was identifed. This is supported by:
- Quality Practice Alerts (accessed here)
- 7 minute briefings – Completed following a single incident to provide an overview of the incident and the findings.
- Thematic 7 minute briefing: Following the identification of a theme as above.
Oxford Learning Events
The Oxford Model is a serious untoward incident / complaint rolling review process which is a way of taking forward the lessons learnt and sharing that learning with a broader audience. Each incident or complaint will already have been reviewed; this process provides the possibility of identifying further issues or concerns and also involves staff in the improvement process. The overall aim is to identify improvement actions on an individual, team and service level. Staff can also access this training via the Learning and Development Prospectus – Section Four.
Update on Quality Improvement initiative
Due to an increase in self harm incidents in Secure and SpLD division it was identified that most incidents occurred on a few wards: Delamere (medium secure unit female SpLD ward) and Chesterton (low secure unit female mental illness ward). The Centre for Perfect Care is working on a quality improvement initiative with Delamere ward and an update as the work progresses will be included in the Division’s bi-monthly report to the Strategic Patient Safety Improvement Group.
Learning from claims
The most common type of claim relates to staff who have sustained injuries from being assaulted by patients when carrying out their role. Liability is denied on approximately 70% of these claims as the assaults are often unforeseeable, staff have received appropriate PSS training to be able to manage restraints and deal with instances of violence and aggression, the patient has robust care plans and risk assessment and are on appropriate observations, the incident has been well managed and staff have responded appropriately.
Other common themes include injuries sustained during a patient restraint, slip/trip claims, and the management of pressure ulcer/wound care (clinical negligence). Slip trip claims are often settled due to wet floor signs not being present at the time the claimant slipped.
Patient death is also a common theme across the Trust and the claim usually follows from an inquest hearing where the family are legally represented.
When claims are received, it is important to gather all the evidence and respond within the legal portal timeframe of 30 days. The claims team rely on the services within the divisions to support this. The process recently developed, where meetings with the relevant team managers are held, has significantly helped to support this and enabled the claims manager to respond within the claims ‘portal’.
Improving our reporting culture
Trust wide innovations have been introduced to challenge some of the barriers to incident management reporting. The Patient Safety Team have implemented the developments below to support how we manage incidents more effectively :
- Incident reporting forms - standardising as much as possible across the Trust including mandatory fields in preparation for the changes to incident management
- Central exception checks of data being carried out in conjunction with the governance teams in each division on a weekly basis
- Refresh of Trust policy for the approval of incidents
- Training on how to manage incidents in line with Trust policy continues to be delivered by the Patient Safety Team
- Regular hints and tips issued via communications.
The Trust’s level of harm remains in line with the NRLS average with an 80% no harm, 20% split. Work is ongoing to improve the recording of harm at source and standardise the recording of harm across divisions. The Patient Safety Team continue to support the improvement of the recording of phycological harm, updates will be shared in future reports.
Coming Soon - Incident Management System
Following the opportunity to tender against a comprehensive specification, an incident management supplier procurement assessment took place in March 2022 which saw three system demonstrations. The panel for the assessment day included representation from across the Trust including our procurement team, patient safety team, Informatics, other corporate services, along with divisional clinical and governance representation. Work continues with procurement ahead of the final decision and proposed timescales for implementation further updates will be shared as available.
Serious Incident Management is changing!
The trust has embarked on the launch of the Patient Safety Incident Response Framework (PSIRF); this will replace the Serious Incident Framework (SIF).
The PSIRF is part of the NHS Patient Safety Strategy and outlines how providers should respond to patient safety incidents. It will be implemented in all NHS organisations starting in Spring 2022.
Instead of having a defined list of serious incidents, there will be a systems-based learning approach to patient safety with a smaller list of incident categories that will need to be reported externally (via StEIS). This will include Never Events, Patient Deaths, Mental Health Homicides and Maternal and Neonatal deaths which meet “Each Baby Counts” criteria.
Patient Safety Team Clinics
Serious Incidents and Duty of Candour clinics are now available every Tuesday and Thursday afternoon between 1.30pm and 3.30pm. The serious Incident clinics have been arranged to support lead reviewers undertaking learning reviews as part of the SI framework. To book a place on one of these clinics please contact: seriousincidents
Claims/Inquest the inquests and claims team commenced bi-monthly surgeries with the divisional governance leads and members of senior leadership teams. Complaints Surgeries are held weekly with members of senior leadership teams from the Divisions.
If you require any further information about the Patient Safety Team please click the link. https://yourspace.merseycare.nhs.uk/patient-safety-team
Corporate Governance – Policies and procedures
The patient safety team will now lead (from August 2022) the corporate policy/procedures review group to ensure a standardised approach on reviewing these important governance documents takes place across the Trust for policies/procedures led by Corporate teams. The review group will report to the corporate safety huddle by exception on any areas of concern or to share examples of good practices that take place from the reviews undertaken.
The terms of reference for the corporate policy/procedures review group will be considered (including membership an work remit) and agreed at the first meeting in August 2022, where the schedule of reviews to take place across Corporate teams will also be discussed and agreed for the remainder of 2022/23 and onwards on a annualised basis, incx§x§line with policy review dates currently on all Corporate policies/procedures.
If you require any further information about corporate policies/procedures please contact: CorporatePoliciesAdmin