Public Board of Directors papers 27.01.22

Objective 2

Greater insight, transparency and triangulation of data

This is important to improve early identification of risk, focus mitigations in the right areas, improve patient safety and ensure staff feel safe to raise concerns LAUNCH THE TRUST PATIENT SAFETY INCIDENT RESPONSE PLAN ACCELERATE A SAFETY II CULTURE How will we do it; 1. USE a full range of intelligent risk information from risk assessments, patient safety investigations, workforce, patient experience, claims, complaints and performance data to develop the Trust Patient Safety Incident Response Plan 2. IMPLEMENT ‘Learning from Excellence’ to identify why things routinely go right in healthcare (Safety II) as well as responding to what goes wrong 3. INCLUDE near miss reporting in existing Datix training to support early identification of risks. 4. STRENGTHEN the integration of clinical audit and improvement into the risk management systems through routine triangulation with incidents and complaints/claims in reports 5. INTRODUCE the use of Quality Improvement progress scores to projects. This aids identification of improvement and celebration of impact on patient care. 6. EVALUATE the impact of medical examiners on the system for reviewing and learning from inpatient deaths 7. IDENTIFY if staff feel psychologically safe to raise concerns by undertaking a face to face staff survey 8. IMPLEMENT the use of a human factors investigation tool to identify systems based causal factors and risks that arise from all incident investigations.

Risk management strategy and Policy 2021-2024 Document ref: RM01 Version 04

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