Duty of Care
The NHS has a duty of care
towards patients, employees and the public by mitigating risk of injury, death or
damage in its activities. However when things go wrong they can have a huge impact,
as evidenced in some high profile cases in recent years. Because of this, close
attention is paid to manage random events with potentially damaging consequences
- Serious Untoward Incidents. Where a SUI occurs, it
must be managed to minimise
damage to patients, employees, property and the public at large. It is also important that organisations learn from the experience, re-evaluate policies and procedures
to prevent recurrence wherever possible.
Profile of a SUI
A Serious Untoward Incident (SUI) is an event such as:- Serious Injury or Death
of a patient, employee, visitor, contractor or member of the public to whom the
NHS organisation owes a duty of care.
✦ Death which is sudden, unexpected, suspicious, or where suicide is the possible
cause.
✦ Where policies or procedures were not followed by staff leading to a detriment
of care.
✦ Serious damage to NHS property through accidental or deliberate means.
✦ A public health risk due to viral, biological or chemical hazards.
✦ Large scale theft, fraud or other criminal activity.
Best Practice
All NHS organisations
must have a strategy for handling SUI’s to minimise the impact, prevent a recurrence
and promote patients’ best interests and well being. Although organisations respond
differently, there are key stages common in managing any SUI.
Stage One - Initial Response.
Standard Operating Procedures (SOP) will determine
how to respond to and contain a SUI, for example:-
✦ Make the area safe, call further emergency services, attend to anyone requiring
treatment.
✦ Notify all designated personnel within the organisation e.g. Chief Executive or
Senior Director.
✦ Notify appropriate external contacts such as:-
✦ The Police, GP, Coroner (as appropriate)
✦ Medical Devices Agency, (if equipment failure / misuse is suspected)
✦ National Patient Safety Agency (patient related issues)
✦ Health and Safety Executive (potential impact on staff, patients and public)
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✦ Child Protection Committee
✦ Medicines and Healthcare Products Regulatory Agency (MHRA)
✦ NHS Counter Fraud and Security Management Service (CFSMS)
✦ Strategic Health Authority (SHA)
✦ Director of Public Health
Stage Two - Investigation.
The purpose of the investigation is to obtain
a detailed record of time-line and events involved of the SUI. However, ascertaining
all known facts can be a laborious, time-consuming task that must be completed as
quickly and accurately as possible. Typical questions that will be asked are:-
✦ What happened?
✦ Where and When did it happen?
✦ How did it happen? (immediate cause)
✦ Why did it happen? (underlying/root cause)
✦ What impact did it have? (on People, Organisation, Resources)
✦ What factors could have minimised the impact of the event?
Once collected, all known facts will be stored, analysed and shared with other interested
parties.
Stage Three - Report.
SUI’s can be sensitive and a key consideration will
be to preserve patient confidentiality. Unauthorised release of a report can cause
problems so there will also be a set of procedures to vet, authorise and release
information to the media and the public. Typically, the Enquiry Report will be submitted
to the Chief Executive and discussed with senior colleagues prior to general release.
It will include key recommendations and a plan to improve clinical quality and patient
safety and reduce the risks of recurrence.
Stage Four - Action.
Whatever the report recommends, the key will be to ensure lessons are learned
throughout the organisation and the wider health community. Specific actions will
be implemented and typically, attention is focussed on training, development and
organisational reform together with changes in business processes and supporting
information systems. |
Optimising SUI Processes
Managing a SUI is perfectly suited to Business Process Management - Actions are
taken by People using Technology to achieve a desired outcome. However, the design
of a BPM system to manage this will be influenced by the existing structure of an
organisation, the services provided and the specific processes followed. A SUI system
that is applicable to all organisations is, therefore, unlikely to be feasible.
So whilst common principles can be identified and used to form the basis for ‘Best
Practice’, the ability to be able define personalised processes and supporting information
systems is crucial. This is why we developed AuraQ Guardian to Optimise Business
Performance in the management of a SUI.
What we do
We are a consulting and software development company with extensive knowledge of
BPM and the NHS. We have a proven track record of successful Business Performance
Optimisation projects and we bring fresh thinking to the process of managing SUI’s.
Business Process Management
BPM comprises software modelling tools to create or modify business processes and
then generate supporting software that can be integrated with other systems as required.
This can not only be achieved in a fraction of the time taken by other methods,
it also leverages existing information systems, protects investment and promotes
collaboration between I.T. and business users to drive efficiencies. The BPM platform
we use to develop AuraQ Guardian is Metastorm BPM®.
AuraQ Guardian
Working with organisations in the NHS, allied bodies and acknowledged experts, we
developed AuraQ Guardian specifically to manage SUI’s. It has been designed with
a few key principles in mind:-
✦ Management of a SUI requires a defined set of processes and actions to be executed
to achieve a defined outcome.
✦ Information must be gathered, analysed, interpreted and shared between a network
of contacts in the most efficient way.
✦ It should be a highly configurable system that can be easily and cost effectively
adapted to specific ways of working.
✦ It should be intuitive and very easy to use.
AuraQ Guardian is part of the Healthcare Optimisation Framework, a series of tools
we have designed to help NHS organisations optimise performance in specific areas
of operation. |
Benefits
This depends on your starting point. If SUI’s are a combination of manual and automated
systems then the potential benefits will be huge, for example:-
✦ Control - all information is contained in a secure database so nothing is lost.
✦ Efficiency - a fully automated system will be faster, more efficient and far more
costeffective than manual or semiautomated alternatives.
✦ Connectivity - enables faster, more effective communication between different
groups with obvious operational benefits.
Reference Points
Metastorm ProVision® and BPM® are used by some familiar names in the U.K.
And some of the most progressive thinking organisations in the private and public
sector and recognisable brands around the world such as :- BBC, Coca Cola, Home
Office, Shell, HSBC, London Transport, Lloyds of London, Ericsson, Fiat, Saab and
the NHS.
Metastorm in the NHS
Although used for
managing referrals rather than Commissioning,
Metastorm is being used in
the NHS today at North Staffordshire Health Intelligence
Service. The Stoke Musculoskeletal Appointment Slot Hospital Early Referral System
(SMASHERS) project, uses Metastorm BPM® to manage the terms of a primary care service
for the triage, assessment and treatment of patients with musculoskeletal problems.
Electronic referrals are generated by General Practitioners (GP) offices and forms
are pre-populated with patient demographics for faster entry and then automatically
routed to the appropriate staff member for action. This helps move patients through
the system and allows GPs to deliver timely care to its patients. North Staffordshire
now plans to use Metastorm BPM® in additional areas including its Rapid Access Chest
Pain Clinic referrals - a process comparable to its initial automation project except
with a focus on cardiac patients. By automating this process, patients now receive
care in a matter of hours. Another core process that has been automated is Incident
Reporting - a critical procedure that tracks any incident that occurs on the clinical
or administrative side and routes the incident form to appropriate personnel for
action. The system documents and tracks explanations for risk management and audit
purposes. North Staffordshire has also automated a process known as Establishment
Control, which is used as its electronic recruitment system for job posting authorisations.
Metastorm BPM® is seen as a critical system and will continue to be used to automate,
and control core processes to enable North Staffordshire to achieve its goal of
improving the health and welfare of its local communities. |