Incident Management&Root Cause Analysis

NHS England Adult Screening Thursday 10 November 2016

Deepak Rikhi, Commissioning Manager, Adult Screening, NHS England (London)

Managing Safety Incidents in NHS Screening Programmes

Providers, Commissioners and QA should all have the read the “Managing Safety Incidents in NHS Screening Programmes”. This can be found on the GOV.UK website:

https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes

The documents:

Describes what is a screening safety incident

Provides guidance that sets out the requirements for managing safety concerns, safety incidents and serious incidents in NHS screening programmes

Safety Incident Assessment Form (SIAF) The SIAF assessment form is used for:

Fact finding

Recommendation for action

Accountability, roles and responsibilities for managing screening safety incidents and serious

incidents

All parties should agree on accountability, responsibilities and governance. A RASCI framework should be used to aid this.

RASCI FrameworkResponsible

• who is responsible for carrying out the entrusted task?

Accountable

• who is responsible for the whole task and who is responsible for what has been done?

Support

• who provides support during the implementation of the activity / process / service?

Consult

• who can provide valuable advice or consultation for the task?

Inform

• who should be informed about the task progress or the decisions in the task?

Responsible

• Where along the pathway did the incident occur?

• If the incident occurred in the screening part of the pathway only, than the Screening Programme is responsible for leading on the incident.

• If the incident occurred in the treatment part of the pathway only, than the Trust hosting the vascular service is responsible for leading on the incident.

• If the incident involves multiple providers, than the Commissioners will lead on the incident

• QA responsible for providing advice on methodology for investigation.

Responsible

• What does being Responsible mean?

• Investigate the incident, i.e. completing the RCA

• Arranging and chairing meetings, such as incident panels, ensuring all stakeholders are invited. This would also include the minuting of such meetings

• Keep all stakeholders informed of progress

Accountable

• This is not always obvious and can be confusing.

• The Lead/Director of the service provider leading the incident is accountable for the incident

• The Accountable Commissioner (NHS England that commission the service) is accountable for having oversight and closing off of incidents.

Support

• These will be individuals or organisations that help those leading an incident in completing the task, e.g. if an incident has occurred with a screening of an image, the CST will support the Programme Manager in the investigation, or the Trust Management providing resource.

Consult

• Who can help?

• Those leading on the incident should look towards QA and Commissioners as a minimum of those that can consult on the incident process.

• It should also be any person or organisation that will help in the investigation, outcomes and lessons learned, e.g. if a patient dies during the treatment pathway, the vascular consultant would be consulted to provide expertise that would inform the investigation

Inform

• Relevant stakeholders need to notified on the progress, outcomes and lessons learned, e.g. the Directors of Public Health, CCGs, etc.

Root Cause Analysis Root Cause Analysis is an evidenced based, structured

investigation process which utilises tools and techniques to identify the true causes of an incident or problem, by understanding what, why and how a system failed.

Analysis of these system failures and true causes enables targeted and, where possible, failsafe actions

to be developed and implemented which demonstrate significantly reduced likelihood of recurrence

Taylor-Adams (2011)

Basic elements of RCA investigation

WHAT

happened

HOW it

happened

WHY it

happened

Unsafe Acts Human

Behaviour

Contributory

Factors

Solution Development & Review of effectiveness

‘WHO did it’

is not the objective

Why RCA? To prevent an incident happening again

In depth analysis of a small number of incidents will bring greater dividends than a cursory examination of a large number.

Vincent and Adams - 1999

Why RCA?

To err is Human

To cover up is unforgivable

To fail to learn is inexcusableSir Liam Donaldson

Hope is not a strategy...

Aiden Halligan

Key Points – What is RCA? RCA Investigations provide a systematic means of

reviewing and learning from incidents

The scale of the patient safety problem is still not clear...

...But it is significant, and to fail to learn in inexcusable

Manage Affected Subjects Ensure affected subjects do not come to harm

Ensure appropriate communication to affected subjects