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Root Cause Analysis Masterclass

Course Overview

In March 2018 NHS Improvement stated: 

“Investigations must be led by trained investigators with the support of an appropriately resourced investigation team”

“while RCA is widely used and considered to be the national systems- based investigation method, it is often not understood or appropriately adopted in local investigations. The RCA method is sometimes cited as the cause of investigation flaws, but review of such published critiques suggests problems with implementation rather than fundamental flaws in the RCA methodology”

The future of NHS patient safety investigations. Proposed principles for the revised Serious Incident Framework

This interactive and practical course will provide a systems based methodology to investigate incidents from an initial understanding of the legal and factual context, through a detailed analysis of the issues and evidence, to production of the formal report.

Delegates will be provided with an electronic toolkit after the training, containing policy, report, statement and timeline templates to help put our RCA methodology into practice.  

Day 1 

This day will focus on the RCA methodology; information gathering, involving patients, families and carers, data organisation, analytical skills, drafting actions, recommendations and observations. 

Day 2 

This day will focus on the skills of statement writing and interviewing techniques.  Delegates will undertake a mock investigation from start to finish, submitting their reports and receiving feedback. 

Content

  • Scoping and information collection
  • Data organisation
  • Interviewing in a no-blame context
  • Scrutinising evidence obtained
  • Identification of care and service delivery problems
  • Identification of contributory factors
  • Identification of failing and missing systems
  • Drafting actions, recommendations and observations
  • Time management
  • Assisting witnesses to produce excellent statements
  • Guidance on precision writing
Root Cause Analysis – A Beginner’s Guide

Course Overview

This interactive and practical course will provide a structured approach to incident investigation.  Delegates will be guided through gathering the evidence, conducting a detailed analysis of the issues and evidence and production of the final report.

The methodology taught will be one that can be incorporated into the health professional’s working day.

All techniques will be tested through role-play.

Content

  • Working out how much information to gather 
  • How to produce a simple timeline and how to fill in a tabular timeline
  • Identifying care and service delivery problems, contributory factors, inadequate and missing systems and producing measurable recommendations
  • Putting together the final report and trend analysis
  • How to manage your time including practical guidance on running an investigation at the same time as undertaking your usual role
  • How to increase staff confidence in producing reports and ensure a consistent approach across an organisation with the provision of report formats and checklists 
Root Cause Analysis Quality Assurance Masterclass

Course Overview

This course will equip delegates with the skills to scrutinise and feedback on Root Cause Analysis investigation reports.

Delegates should ideally already be familiar with the tools and methodology required to complete a rigorous RCA investigation.  However, the training will include a refresher of the fundamental principles.

The training will focus on applying these principles to the critiquing of, and feeding back on, RCA reports.  The session will be case study led using an anonymised incident report although delegates can bring along their own (non-live) anonymised incident reports to the training. 

Content

  • Establishing that the investigation report has a sound evidence base
  • Ensuring the correct use of simple and tabular timelines (the core documents in a RCA investigation) 
  • Making sure the analysis is robust; CDPs/SDPs/Contributory Factors/Failing and Missing Systems
  • Critiquing recommendations/action plans
  • Insisting on precision writing 
  • Providing effective and supportive feedback 
  • Ensuring the focus is on learning
Social Circumstance Reports – Preparation and Presentation

Course Overview

Practical challenges exist for practitioners preparing and presenting effective and relevant social circumstance reports.  Time limits are short and every case is different.  

This training day will assist delegates with time and template management to ensure a consistently high standard of report production and presentation. 

The emphases of the day will be confidence, clarity and compliance.

Note: this course refers to the position in mental health cases before the First Tier Tribunal in England.  

 Content

  • Ensure a solid understanding of the provisions of the Mental Health Act 1983, Tribunal Procedure (First Tier Tribunal) (Health, Education and Social Care Chamber) Rules 2008 and the Practice Direction First-tier Tribunal Health Education and Social Care Chamber: Statements and Reports in Mental Health Cases
  • Understand what a Tribunal wants from a report: format, content, length and tone
  • Develop your legal literacy
  • Review requirements for in-patients, community and guardianship patients, conditionally discharged patients and patients aged under 18 years
  • Learn the legal principles relating to disclosure of information, and when documents or information may be withheld
  • Using templates and how to develop a report checklist
  • Understand the Tribunal process and learn evidence presentation skills
  • Role-play: produce and present a short report and receive constructive criticism or bring along an anonymised report for critique
The Organisational Duty of Candour

Course Overview

This one-day in-house course, led by an experienced Barrister and Accredited Mediator, covers the legal and professional regulatory framework surrounding the duty of candour, the background to the duty and what it means in practice.

The training will include sessions on meeting and communicating with patients and families. It will also cover what is a notifiable safety incident (both in an NHS and non-NHS context), moderate and severe harm, making apologies, compensation, supporting staff, an overview of Root Cause Analysis and record keeping. 

The emphasis will be on developing the practical understanding of the key concepts and the skills needed to ensure compliance with the duty of candour. 

Content

  • Fundamental principles and policy background – what is the duty and why is it there?
  • Statutory framework – NHS Trusts, primary care and others
  • Professional duty and Codes of Practice
  • What is a ‘notifiable safety incident’?
  • The threshold(s) for a notifiable safety incident – when does the duty engage?
  • Required actions: notification, investigation, apologies and documentation
  • Accountability and responsibility: organisations, clinical leads and individuals
  • Apologies and admissions of liability – are these the same?
  • Meeting with patients, service users and families
  • Investigating incidents – using Root Cause Analysis
  • Communicating in writing – clear, accessible and person-focused
The Statutory Duty of Candour – Scotland

Course Overview

This one-day in-house course, led by an experienced Barrister and Accredited Mediator, covers the legal and professional regulatory framework surrounding the duty of candour in Scotland under the Health (Tobacco, Nicotine etc and Care) (Scotland) Act 2016 and the 2018 Regulations.  

The training will cover the key points of the duty, the Scottish Government’s Guidance and how these apply in practice.  This training has been developed drawing on our extensive experience of delivering training on the comparable duty of candour in England. 

The emphasis will be on developing the practical understanding of the key concept, and the skills needed to ensure compliance with the duty of candour.   This training will help you to use the duty of candour to develop a culture of safety and provide person-centered care. 

Content

  • Fundamental principles and policy background – what is the duty and why is it there?
  • Statutory framework – NHS Trusts, primary care and others
  • Professional duty and Codes of Practice
  • What is a ‘notifiable safety incident’?
  • The ‘harm thresholds’ – when does the duty engage?
  • Required actions: notification, investigation, apologies and documentation
  • Accountability and responsibility: organisations, clinical leads and individuals
  • Apologies and admissions of liability – are these the same?
  • Meeting with patients, service users and families
  • Using candour to de-escalate conflicts
  • Using the duty of candour to develop a culture of safety and provide person-centered care
  • How candour can help make investigations more effective and person focused
  • Communicating in writing –  being clear, accessible and person-focused
End of Life Care – Legal Issues Introduction

Course Overview

This half-day course will provide healthcare practitioners involved in palliative and end-of-life care with an introduction to the legal framework in which they practice. 

The course will cover the basic statutory and common law framework that governs how a healthcare professional can treat and care for those at the end of their lives.

Through case studies the course will explore the implications of best interest assessments and the Deprivation of Liberty Safeguards (DoLS) in end-of-life care, clarifying the key legal issues and how they apply in practice.  

Content

  • Outline the key principles of the Mental Capacity Act 2005 and how it applies in day-to-day practice in end-of-life care
  • Using common law principles – standard of care and consent
  • Undertaking and documenting capacity assessments 
  • Best interest assessments and an overview of DNA CPR
  • How human rights can help support effective, personalised care
  • Deprivation of Liberty, the Cheshire West case and the ‘acid test’ – how do these apply in end-of-life care?
  • Independent Mental Capacity Advocates – their role and how they can support you and your patient
End of Life Care – Legal Issues Advanced

Course Overview

This one-day course will provide healthcare practitioners involved in palliative and elderly care a detailed knowledge of the legal framework in which they practice. 

The day will cover capacity and best interest issues in end-of-life care, and how healthcare professionals can best engage with patients and their families to make decisions together. The course discusses how patients can record their wishes in Lasting Powers of Attorney, Advance Decisions and Advance Statements and how these affect the care and treatment provided. The course looks at the law, process and guidance relevant to DNA CPR notices.   It will also consider how deprivation of liberty can apply in end-of-life care and the rights of patients.  The course will incorporate relevant guidance, including from NICE, GMC and BMA. 

There will be in-depth discussions around case law and best practice along with guidance on how to assess documentation and when to seek advice.   The training has a practical focus and uses case studies and caselaw to help you to explore the issues and enhance your practice.

The course is suitable for those who already have a clear understanding of the Mental Capacity Act,  including capacity and best interests assessments.

Content

  • Understanding the key legal issues 
  • Capacity and best interests issues in end of life care
  • Lasting Powers of Attorney – what these are and how they work
  • Advance Decisions to Refuse Treatment – what are they and what do you need to do
  • Advance Statements – why these are important
  • Do not administer CPR (DNA CPR) Notices – the law and process
  • Deprivation of liberty and patient rights at the end of life
  • Having difficult conversations: patients, families, carers, colleagues
  • Exploring guidance – including from NICE, GMC and BMA
Giving Evidence at Coroner’s Court

Course Overview

This is a course for healthcare professionals who may have to give evidence at an Inquest.  It is also suitable for those who may have to support staff in the immediate aftermath of a patient death and at Coroner’s Court. 

The day is split into two sections; section 1 covers how to prepare to give evidence and section 2 covers giving evidence at Inquest.  

Every delegate will be cross-examined by a Healthcare Lawyer and Inquest Advocate to experience, in a protected environment, the level of scrutiny their evidence may be subjected to.  Every delegate will be given personal feedback and guidance on how to improve their own, individual presentation skills.  

NB – no live cases will be discussed

Content

  • Writing witness statements
  • Critical analysis of evidence 
  • What to wear
  • Language to use
  • What to expect on the day
  • Interface between a Serious Untoward Incident Investigation and Inquest
  • The purpose of an Inquest
  • What about staff who have left?
  • Court visits
  • The difference between an expert and a witness of fact
  • Giving oral evidence
  • How to deal with lawyers’ techniques
  • Jury Inquests
  • Conclusions and PFD Report
Complaints Handling

Course Overview

This interactive and practical course will provide a structured approach to complaints handling through the use of Root Cause Analysis.  

The day will also cover letter writing, communicating with patients and families and conducting interviews. 

All techniques will be tested through role-play.

Content

  • Overview of Root Cause Analysis as it relates to complaints handling
  • Scoping the complaint
  • Interface with the Duty of Candour and complaints procedure
  • Meeting with patients and families
  • Letter writing
  • Interview techniques
  • Time management