In the last few months our new CQC Compliance Manager Lorna has been examining our incident reporting process and writing a policy as part of reviewing StanleySmith Case Management’s clinical governance processes.
Although it was already robust, at SSCM we are always looking to continuously improve. SSCM decided that the need for change was based on:
- Needing an accurate description of the event and its impact on the client – this wasn’t always easy to establish on the previous format
- Consistency and comparability within the organisation to facilitate in capturing data
- New harm grading in line with the new NHS “learn from patient safety events” which, if needed, allows us as an organisation to share out data more widely with other NHS and social care providers.
- Clear harm grading definitions
- New categories of the “types of incidents” with a working definition which helps with accurate recording
- A new MACH actions arising form, which allows Case Managers to clinically review the incident and finalise the incident category and level of harm. This enables the incident and clearly records if the incident investigation is closed or needs further investigation.
- The new actions arising MACH form also prompts the case manager to evaluate and record how they will prevent similar incidents and how they have delivered feedback
Lorna first looked at the incident reporting forms used by care teams, which are completed by filling in a mach form which gets sent to the relevant recipients automatically via email. She then looked at the actions arising form which is completed by a case manager post incident. After making the changes which included the harm grading with definitions, she drafted the new incident reporting policy.
The new incident policy forms part of SSCM commitment to excellent and safe care and clearly outlines policy and processes to reduce incidents by ensuring that systems are in place that will enable all incidents and near misses to be accurately reported, investigated, root causes understood and appropriate corrective action taken. The policy clearly sets out reporting and investigation responsibly, together with timelines for investigation.
Investigation feedback is encouraged not only within the client’s individual teams but within the wider organisation. Investigation feedback now forms part of the case managers quarterly team meetings.
The new forms and policy were sent out to all of our associate case managers and support workers working with us and they were invited to provide feedback. Adjustments were made to the new forms when appropriate in line with this feedback
The forms are now currently in the process of being made client specific and distributed to each care team and their respective case manager and will be easily assessable to both the clients teams and case managers.
We look forward to seeing how the updated process and forms assist in capturing accurate data which can be analysed, fed back to teams and can assist in training exercises in the future.
