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Jerome P



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  1. Content Article
    It’s been a really difficult time for all of us this past year. When I say ‘we’, I mean every single person on the planet. I am yet to find anyone who hasn’t had to deal with stress, mental health problems, anxiety, illness, disappointment or bereavement of some nature over the past year. Collectively, we are all going to need a period to heal. I fear that the healthcare system will have no time to heal and that we are only on the tip of what more there is to come. Not only has the healthcare system had to deal with a pandemic, we have had to deal with the consequences from that. The backlog of operations that have been cancelled, the mental health crisis that has arisen out of an already underfunded system which is now overwhelmed, NHS staffing issues, holes in social care, the pressures on primary care and the ambulance services – these are all recognised as huge issues that are affecting patients. I want to highlight the problems that will rear their ugly heads in the coming few months and years to come and, possibly, cripple the NHS. I don’t know how we will deal with them. I want to push for guidance and support from NHS England as this will impact the governance of patient safety. Increase in serious incidents and never events As a patient safety manager, part of my role is being involved in investigations and supporting the clinical teams to undertake a root cause analysis of the incident. In the Trust where I work, we pride ourselves on being open and honest and have a healthy reporting culture. Never has reporting been as important as now. We are learning all the time – we are working in new ways, electronic systems are rapidly taking over many face to face meetings and consultations. If we don’t know the problems, we won’t be able to improve. To add to that, the Trust has never been so busy, so stretched, so tired – so mistakes will be made. With this culture of reporting, the serious incidents and never events are exposed, as an increase in activity, staff redeployments, different areas of the hospital being used as ITUs or repurposed give rise to incidents. Human factors surely must be the largest contributing factor of why incidents are occurring at present. This give me an uneasy feeling that governance systems are going to be under enormous pressure in the coming years. I am starting to see some of the fall out already. There has been an increase in ‘lost to follow up’ where I work. This is when a patient is referred to a service for a consultation; for example, if a patient has a long term condition such as diabetes and they need follow up for podiatry a referral is made. The referral is picked up and appointment made accordingly. This may mean that a patient needs to be seen in two weeks, three months – depending on the urgency. Referrals getting lost So why are referrals getting lost? Here are a few reasons: Many of our staff have been redeployed, either to vaccine hubs or to support the wards with admin tasks. Staff do not always know the procedures and protocols they need to work to and referrals don’t get actioned. Administrative staff have taken on extra roles to reduce back log and work either extra hours or take on extra responsibilities. Paperwork will get missed, handovers won’t get done or in a timely way. Staff are tired. Morale is at an all-time low. They cannot work harder or quicker. Juggling too much work means mistakes will be made. We are using new systems to accommodate different ways of working, often with interim staff navigating this. Staff won’t be clear what is needed, maybe new systems will have teething problems that won’t be spotted, alerts and follow ups won’t be flagged or actioned. The volume of work has increased and, due to long waits, acuity of patients has increased. Changes in patients acuity might not be flagged or responded to so that urgent priorities might not be actioned. ‘Died on the waiting list’ The second increase has been ‘died on the waiting list’. Patients waiting for bowel surgery, vascular surgery etc. These patients are seen in clinic by the specialty and placed on the waiting list. While on the waiting list their condition may get worse. At present there is no systematic way of monitoring patients on this list. If there is no way of monitoring them there is no system of triaging them and getting them to surgery at an appropriate time. Patients are dying while on waiting lists. What is worse… we don’t know about this until we invite them for surgery. Each and every ‘lost to follow up’ or ‘died on the waiting list’ that has occurred is investigated. Currently, every Trust in the UK has 60 days to complete a root cause analysis and put actions in place for it not to happen again. In usual times, this would be achieved. Many governance systems have this deadline as a KPI. However, we are now in a time where clinicians are overwhelmed with treating patients on the frontline. They do not have the capacity to be involved in root cause analysis. Multi-disciplinary meetings need to take place – clinicians do not have the time to schedule these meetings as they are working flat out. Thankfully, this has been recognised by our local Clinical Commissioning Group (CCG). They have given us a grace period, we are no longer bound by the 60 day rule. This will now lead us into a backlog of investigatory work. It leaves me with so many questions: How can an investigation take place weeks or months after the event? Relatives and patients deserve answers – how do we manage their expectations? We are always firefighting – what proactive measures are being used/developed to manage waiting lists? Will every death on the waiting list need to be investigated as the root cause will be the same… COVID pressure/lack of capacity? If patients are ‘lost’ or died – currently we have no way of knowing – this is not acceptable. Is there a better system? Patients waiting to be referred into the hospital The above patients are patients we have inside the hospital system. What about patients waiting to be referred into the hospital? This opens up yet another huge number of patients waiting to see a hospital specialist. For example, you go to your GP with vision disturbances. They then refer you to the ophthalmologist at your local hospital – or if it is an unusual presentation, you may be referred to a specialist centre. The amount of patients being referred into their local hospitals are increasing on a daily basis. This list is not decreasing. This will lead to increased harm to patients suffered from delays. This ever increasing list of patients is currently not being managed, not being monitored or triaged. Where I work there are over 5000 people on this list. It is a ticking time bomb. A latent consequence of this awful pandemic. NHS England, please help NHS England – please give us guidance in how we can manage this. The wave of latent harm is on the horizon for hundreds of thousands of patients. Patients need to know what to expect and what their rights are. We needs guidance on the management of waiting lists in hospital. We need guidance on managing waiting lists to see a specialist from primary care. We need guidance on managing these potential, historical investigations. The NHS is already drowning. If patients are harmed or have died as a result of long waits and not investigated, expect litigation. We need open and honest discussion about this. The time to act is now.
  2. Content Article Comment
    Hi @Jon Holt Ive been saying that actions don't reflect the true root causes for a while. This is an elephant in the room. Im hoping the new framework will help. But the old world usually bites back, and usually twice as hard. What is the solution?
  3. Content Article Comment
    I completely agree with you @Katrina. More often than not, post RCA, there are numerous actions but little assurance that they are being completed in a timely manner. Readdressing the balance is so important. The Patient safety managers voices are so very small - we all know its not right...so why are we not kicking up a fuss?
  4. Content Article
    What is root cause analysis? Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again. This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework. What happens to the report? Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. What type of incident is RCA used for? Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events. Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors. What is the process? The current process of undertaking and processing a serious incident is laid out below. This is taken from the NHS Serious Incident Framework. Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician. How long does it take to complete an RCA? This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information. If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks. How many RCAs are completed each year in the UK? During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. Currently, patient safety teams up and down the country are drowning in writing RCA reports. We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented. The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff. This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept. Multiple drafts are written before submitting the final report. Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure. Once written and signed off by the Trust and the CCG – the RCA is complete. What happens next? The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time. At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident. One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS. Final words Have we forgotten the purpose of our role within patient safety? Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm. It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. What are your solutions to action plans and gathering the evidence for these plans? Have you a system that is easy to keep track of RCA reports and follow up? I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want?