Organisational Learning Policy

Transcription

1 Policy Authors Name & Title: Dr Mark Jackson, Director of Research & Informatics Scope: Trust Wide Classification: Non-Clinical Replaces: v1.4 To be read in conjunction with the following documents: Risk Management Policy Incident Reporting Policy Litigation Policy Complaints Policy Mortality Review Policy Document for public display? Yes Unique Identifier: TC02(08) Review Date: July 2019 Issue Status: Approved Version No: 1.5 Issue Date: 24 th Authorised by: Risk Management Committee Authorisation Date: 28 th After this document is withdrawn from use it must be kept in an archive for 10 years. Archive: Document Control Date added to Archive: Officer responsible for archive: Document Control Administrator Has document been Equality Impact Assessed? Has Endorsement been completed? No No Page 1 of 8

2 POLICY STATEMENT Liverpool Heart & Chest Hospital NHS Foundation Trust needs to learn from its experiences to continuously improve the care it provides to its patients, carers and families. This policy provides a standardised framework for the feedback of information from the Trust s experiences into the Divisional governance process, the identification of actions for improvement, subsequent assurances and how these are shared across the organisation to promote organisational learning. 1 Role and Responsibilities The Director of Research & Informatics has responsibility for development and implementation of this policy. Managers of Quality & Safety functions within the Trust have responsibility to identify experiences from which the Trust could usefully learn. These functions include, but are not limited to: Risk Management (incidents, claims) Patient & Family Experience Clinical Audit Patient & Family Support (complaints, concerns) Mortality Review Safety Huddle The Head of Information Services, together with relevant Managers (above) and associated leads have a responsibility to create feedback systems from the Trusts experiences that are, where possible specific to the Divisions in accord with resources and information available. Medical, Surgical and Clinical Service Divisional senior leadership teams have responsibility to engage in the organisational learning process, extract the learning from such experiences and in doing so identify opportunities for improvement. Additionally they are responsible for obtaining assurance following implementation of improvements to ensure sustainability. s and assurances will be reported by the teams into the Operations Board and to the members of their Divisions so the workforce understands how the organisation has learned. The Divisional senior leadership teams consist of: The Associate Medical Director The Head of Nursing The Divisional Head of Operations The Operations Board have a responsibility to challenge improvements to ensure they are appropriate and commensurate with need, and identify how improvements in one area could be modified (as necessary) for implementation elsewhere in the organisation. The Risk Manager has a responsibility to collate the learning from the Operations Board presentations and ensure comprehensive organisational dissemination. Page 2 of 8

3 2 Protocol The organisation receives feedback all of the time, and on a variety of functions. As this feedback is received, it is reflected in a Divisional specific report for each type of feedback that is sent for review at the Trusts Divisional governance meetings. At the Divisional governance meeting, the senior leadership team lead a discussion with other members and identify opportunities for improvement. A lead responsible person and timeframe for implementation of this improvement is allocated, and the improvement is tracked through to delivery. At the next available section of the Operations Board, the Divisional Head of Operations ensures that the identified improvement, planned or delivered is reported. A structured reporting format is to be used (appendix 1). The Operations Board reflect on the improvement, and challenge it if it does not seem appropriate and commensurate with need. Agreed improvements are further discussed to identify how improvements in one area could be modified (as necessary) for implementation elsewhere in the organisation. s are communicated to staff both within the Division(s) affected by the improvement and organisation wide using a variety of methods (some examples shown appendix 1). Standard methods of cross organisational communication include team brief, weekly bulletins, Pulse, Members Matters and a webpage of improvements in addition to those that are bespoke to the Division and context or setting. To facilitate cross organisational communication yet further, notable improvements will be presented at the Trusts monthly Grand Round. Staff members leading improvements of any scale or nature will be encouraged to present their work to attendees. The meeting will be open to all, and Divisions will encourage attendance where duties permit. At some time after the improvement has been made, the Divisional Head of Operations will ensure that assurances are obtained in order to judge that the improvement has been sustained. Where it has not, further improvement work will be commissioned. The results from these assurances will be added to the structured report and presented at the Operations Board. Further assurance that organisational learning is taking place can be obtained from Executive and / or Non-Executive Directors as part of their walkabouts. Appendix 2 presents a flowchart of how the process works. Page 3 of 8

4 3 Policy Implementation Plan The Director of Research & Informatics is responsible for implementation of this policy. Oversight of the implementation of this policy and resultant learning will be achieved via the Risk Management & Corporate Governance Committee. The Policy will be shared with the Divisions via their Governance meetings. The policy will be made available to staff via the Trusts policy intranet site. Communications regarding the policy being adopted by the Trust will be shared via corporate communications. 4 Monitoring of Compliance The effectiveness of this policy will be measured by: 1. The presentation of improvements and assurances at the organisational learning section of Operations Board. 2. Significant assurance rating on the follow up of improvements (standard = 75%). 3. Improving scores form the national staff survey regarding the question We are given feedback about changes made in response to reported errors, near misses and incidents (5% improvement by 2018; 45% to 50% - rank rating 120 to 70 nationally). Page 4 of 8

5 APPENDIX 1 Issue? Source of Learning (e.g. mortality review, incident, audit, complaint etc.) Delivered How Has Been Communicated? Assurances Received Wider Organisational Learnin e.g. Theatre never event e.g. Mortality associated with poor transfer for ACS PCI Serious Incident Mortality Review Revised standard operating procedure in theatre Standardised communication sheet that all referrers must use Theatre team brief, to all theatre users OL Grand Round Personal letter to all referrers OL Grand Round Audit of compliance > 99% Audit of compliance > 95% Similar policy adopted in all interventional settings Standardisation of all patient transfers e.g. Potential claim poor documentation of VTE prophylaxis Audit data, performance review Structured section in EPR Personal to all prescribers, Trust weekly bulletin, team brief OL Grand Round Audit of compliance > 95% Structural overhaul of EPR to record key process measures and outcomes linked to contract or quality strategy Page 5 of 8

6 Endorsed by: Name of Lead Clinician/Manager or Committee Chair Position of Endorser or Name of Endorsing Committee Date Page 6 of 8

7 Record of Changes to Document - Issue number: v1.4 Changes approved in this document: Date: 24/7/17 Section Number Appendix 1 Amendment (shown in bold italics) Deletion Addition Reason Addition of source of learning column Allows triangulation of learning from multiple sources Page 7 of 8

8 APPENDIX 2 Board of Directors Organisational learning identified Cross organisational action Operations Board Structure Organisational learning assurances & dissemination Structure Structure delivered Assurance received delivered Assurance received delivered Assurance received Medicine Surgery Clinical need identified need identified need identified Version No.1.4 Policy February 2016 Page 8 of 8 Check Divisional with Intranet that Service this printed Feedback: copy is the latest issue Risk Management, Patient & Family Experience, Clinical Audit, Patient & Family Support, Mortality Review, Safety Huddle, Etc.