Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

Board of Directors Meeting, 29 March 2012Agenda Item 1313.3. Managers are responsible for highlighting lessons learned at a local level with staff inteam/service / local governance meetings13.4. All serious incidents reported include a requirement to complete an initial managementreview; this includes recommendations, lessons learned and actions taken/planned bothlocally and corporately.13.5. All Serious Incidents Requiring Investigation are considered by Root Cause Analysisinvestigations. The reports of these investigations are considered by the Trust Risk IncidentReview Group.13.6. All lessons learned identified as a result of serious incidents are considered on a fortnightlybasis by members of the Trust Risk Incident Review Group and fed back to clinicians andmanagers for action as appropriate. Monitoring of these actions is the responsibility of theTrust Risk Incident Review Group. Monthly safety briefings are also developed anddistributed to all managers to feedback learning from incidents.13.7. During the complaints investigation process, feedback forms are completed by theinvestigating officer which identify learning points at both local and corporate level. Theselearning points are reported in the quarterly Patient Experience Team’s report to the Qualityand Safety Committee.13.8. Any risks which cannot be rectified immediately are assessed and considered for inclusionon either a local risk register or the corporate risk register and associated action plans aredeveloped.13.9. Where indicated, relevant policies, procedures and guidance will be amended to reflectchanges in practice as a result of lessons learned from investigations/analysis.14. Monitor and Review:14.1. It can take time to plan and implement change. A robust monitoring and review system isessential to ensure actions are followed through, that priorities are re-assessed, so that riskmanagement is an ongoing process that is embedded into normal management systems. Itis crucial that when undertaking these assessments and reviews that details of when thesewere carried out and by whom are documented.14.2. Continuous monitoring and review of risks ensures that new risks are detected andmanaged, action plans are implemented and managers and stakeholders are keptinformed. The availability of regular information on risks can assist in identifying trends,likely trouble spots or other changes that have arisen.Monitoring Item Action Required/Frequency ResponsibilityAll incident reports includingSerious Incidents, complaints,claims, PALSInitial Management Review ofSerious IncidentsTrust Risk Incident ReviewGroup meeting notescirculated fortnightly to Headsof Practice for informationand action at Directorate levelSerious Incidents andSerious Incidents RequiringInvestigation; investigationsand action plans arising fromTrust Risk IncidentReview Group, RiskManagement Team andPatient Experience TeamPage 122 of 156