INTRODUCTION ULYSSES INVESTIGATION (RCA) MODULE

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1 INTRODUCTION Ulysses Investigation supports all types of investigations from 72 hour review through to full Root Cause Analysis (RCA) and the Serious Incident (SI) process. Each Level of investigation can collect different information guiding the user to provide the relevant data at each stage. The system uses versioning to build on the previous information collected, allowing users to see how the investigation has progressed. Many staff can be involved at each level and they are able to keep a commentary alongside the information, auditing reasons behind the decisions made. The Investigation is an extension of the incidents and complaints process and is available as part of the Management of the information.

2 CUSTOMISATION Ulysses Investigation is highly configurable. The steps within the process, and the information collected at each stage can be tailored as required, adding guidance and links to supporting documentation. The Investigation process is used across Incidents and Complaints, taking the information forward as required and linking to the appropriate events within the modules.

3 WORKFLOW The decision as to whether an investigation should be undertaken and who will Lead can be based on a combination of pre-set rules, for example if Serious Incident is indicated, and / or devolved to Clinical Managers at review. Responsibility for the investigation is allocated through the system, and staff are sent an notification. This notification can be tailored to include instructions, guidance and information about the incident and investigation required. Communication is also tracked through the system.

4 WORKFLOW CONT. When notified, staff are given access to all the accompanying information including the incident or complaint, attachments, previous findings and actions. As the information is built up within the database, staff can contribute to the investigation at the same time, with the assurance that they are working on the correct version. Once the investigation is complete, the user indicates through the system sending notification to the Review panel. Staff can be notified automatically based on Divisional or other information, or contacted individually. The Reviewers use the Comments feature to share their thoughts and reflections. These may also be suggestions for changes to the report, and depending on the organisation s preference they may make those changes or submit to the panel. Either way, the Comments are used to document the reviewers decisions. Different versions can also be created during the Review process auditing the comments and alterations made.

5 THE PROCESS The Investigation combines the clinical information identifying what actually happened and where any mistakes were made, alongside the defined stages of the investigation with target dates and administrative notes.

6 CHRONOLOGY An account of the events leading up to the incident or complaint is recorded systematically, identifying both Problems and Good Practice. The format encourages a structured approach. The level of the investigation may be reflected in the depth of the chronology, and this can be added to in subsequent versions.

7 CONTRIBUTORY FACTORS AND ROOT CAUSES For each identified problem, both contributing factors and root causes are identified. Any additional supporting details can also be entered against each entry.

8 ANALYSIS AND REPORT The Chronology, Root Causes and Contributory Factors are brought forward for consideration at the analysis and report stage. This section includes information such as the background and context for the report, executive summary, findings and conclusions. In addition, Recommendations, Actions and Lessons Learned are determined. Actions are ed to the staff responsible and have Target Dates and reminders. The level of detail and amount of information collected at this stage is decided by the organisation and is dependent on the level of investigation selected. If findings indicate that further review is required, a new version of the investigation is made bringing all the information forward. The previous version, that is the lower level investigation, becomes read only and is preserved for reference purposes. Note that there can be as many levels of investigation as required. In addition, versioning can simply be used to audit any changes made to the record. The RCA process can go through several levels of checking and sign-off depending on the investigation level.

9 PILOT Ulysses recommends that the Investigation / RCA process is piloted by allocating a few investigations centrally to specific members of staff. This should be a small and controlled pilot to start with, and can be widened once it is confirmed that the system s configuration supports the investigation process within the organisation.

10 REPORTS The 72 hour report, full RCA plus other reports can be generated from the System. In addition, there can be more than one version of the RCA report, each designed for a different purpose. For example, an anonymised version for use by Commissioners and CCGs. These reports can include information from the incident(s) and / or complaint(s), and commentary as required. The Stages element of Ulysses allows the progress of current investigations to be tracked, highlighting those that are missing key target dates. Some commissioners have specific report templates. These templates can be recreated within Ulysses using the Extractor and Report Designer, and selected when required. The next example shows a report created for a Ulysses customer being used as part of their investigation process.