Incident Management Policy Including Serious Incidents Requiring ...

17 Performance Management and Data CollectionReported incidents will be formally analysed quarterly considering incidence by category,location and severity and comparisons made to preceding quarters and years. Analysis willbe both qualitative and quantitative in nature, and discuss any trends that have beenidentified as a result of investigations and any themes/trends relating to causal factors.Changes in practice as a result of incidents will be includedSerious incidents requiring investigation will be analysed and learning and changes made asa result of the investigation will be identified.18 Reports to Committees and the BoardThe Clinical Quality and Safety Committee will receive the analysis of incidents on aquarterly basis, bi-monthly for SUIs. It will monitor progress towards achievement of actionsplanned following severe and Serious incidents requiring investigation (action plans for lesssevere incidents will be monitored through the Locality structure) and the impact these haveon incident reduction/trends.The Committee will also receive a Complaints report analysed in the same manner to allowconsideration, comparison and aggregation of incidents and complaints.Through shared membership and notes of meeting, the Clinical Quality and SafetyCommittee will report key incident information to the Board to ensure this informs thecorporate decision making and strategy formulation19 Learning from Experience and Sharing Lessons LearntSharing the lessons learnt through an incident and its investigation is a critical part ofincident management.As set out in Section 25, anonymised incident data, both quantitative and qualitative, such asnumbers, themes and trends, as well as the outcomes of investigations including causes andrecommendations will be analysed and reported to the Clinical Quality and SafetyCommittee by the Head of Governance to highlight any patterns and uncover any need forfurther intervention. Serious incident requiring investigation themes and learning will also bereported to the PCH Board.Learning will, as indicated in the NPSA National Framework 2010, be shared by managersthrough team meetings, staff briefings, newsletters and all user emails where appropriate, toensure the lessons are communicated not just to those directly affected by the actions, but toother groups who may be able to adapt the learning to suit their own services and needs.20 Risk Management Strategy Implementation20.1 Implementation & DisseminationRegular briefings will be provided by the Datix Administrator and circulated byCommunications reminding staff to report incidents using the datix system. Allstaff should be informed of incident reporting at induction or at their firstappraisal.26 of 28