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Virtual Training – Investigating Incidents – Module 1

Description of Module

This virtual training session will focus on the first crucial steps of any incident investigation.  The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day, as well as one that can be conducted remotely. Delegates will be provided with a suite of templates to use during an investigation as part of our commitment to an holistic approach to patient safety.  All learning points are reinforced with real life examples.

Objectives

Ensure a solid understanding of the first crucial steps of an investigation including:

 

  • How much information to gather and how to gather it

 

  • The role of human factors and ergonomics in patient safety incidents

 

  • How to involve patients, families and carers; obtaining evidence and discharging The Duty of Candour

 

  • How to organise evidence using Timelines

 

  • How to critically analyse evidence

Example Timings

 

9.00am to 09.15am    Logon, technical knowhow and introductions

09.15am to 09.30am  Overview of the investigation methodology.

09.30am to 9.45am    Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach, the importance of objectivity and tips for achieving neutrality.

9.45am to 10.15am    Gathering information; a report is only as good as the information it is based on.  Investigators must go beyond simply gathering evidence to find out ‘what’ happened – they must find and ‘why’ it happened and remember to gather human factors and ergonomic evidence. This will ensure that Investigators possess enough evidence to make SMART recommendations.

10.15am to 10.30am  Coffee Break

10.30am to 11.15am  Mapping the information using simple and tabular timelines.

11.15am to 11.45am  Critical Analytical Skills – How to identify missing or incomplete evidence

 11.45am to 12.00pm Conclusion, Questions and Set up for Module 2

Virtual Training – Investigating Incidents – Module 2

Description of Module

This virtual training session will focus on the next steps in any incident investigation.  The emphasis will be on practicality and how important a structured methodology is to ensuring good analysis. Mirroring the new Patient Safety Strategy, good practice and factors requiring change will be identified, along with their contributory factors.  All recommendations, reports and action plans will focus on systemic changes, multi-disciplinary working and implementing practical changes.  All learning points are reinforced with real life examples.

Objectives

 

  • How to conduct interviews with staff members and families

 

  • A guide to precision writing

 

  • Identification of factors requiring change

 

  • Including good practice in reports

 

  • Identification of contributory factors

 

  • Identification of broken and missing systems

 

  • Understand the key elements of a good action plan

 

  • Making proportionate and effective recommendations

 

  • Pulling a report together

Example Timings

 

1.00pm to 1.15pm      Logon and recap on Module 1

1.15pm to 1.45pm      Critical Analytical skills – how to prepare for interviews. How to conduct interviews with staff members and families

1.45pm to 2.30pm      Identification of good practice and factors requiring change.  The importance of standards and precision writing.

2.30pm to 2.45pm      Tea Break

2.45pm to 3.15pm      Identifying contributory factors, including human factors, broken and missing systems.

3.15pm to 3.45pm      Focus on writing excellent recommendations, benchmarking, reasonable/measurable action plans and producing standardised reports.  Example report format provided.

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

Incident Investigation Training; A Systems Based Approach to Patient Safety

Course Overview

We were delighted to read, in the new NHS Patient Safety Strategy (July 2019), that there will be a move away from using the phrase ‘Root Cause Analysis’ to using a ‘systems’-based approach to investigations. Previous participants in our courses will be aware that we have always passionately believed that there is never just one or two ‘causes’ of a patient safety incident and that blaming individuals is a barrier to organisational learning.

The phrase ‘Root Cause Analysis’ has led many organisations and individuals to believe they have to select one or two primary causes and indeed the template that is in general, national usage, currently contains a section encouraging this approach.

To reflect the new direction we have re-designed our Incident Investigation training packages and expanded our methodology to allow even more time to be spent on important issues such as patient involvement, human factors and ergonomics, why things go right, a just culture and the lessons we have learnt from handling legal cases and undertaking investigations ourselves.

As always, our primary focus will be on proportionate and effective learning. We will continue to provide delegates with 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.

The first day will focus on information gathering the collection of systemic evidence: physical, cognitive and organisational data and evidence from patients, families and carers. The next section of the day covers evidence management and critical analytical skills. The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day.

The second day of this interactive training will focus on the skills of statement writing and interviewing and then take delegates through a case study. This section of the course can be tailored to an organisation’s individual needs through the provision of a bespoke case study. Previous training sessions have covered maternity, surgery, mental health, primary care, opthamology, infection control, emergency medicine and dispatch, for example.

We will continue to provide free policy and template reviews for clients as part of our commitment to a holistic approach to patient safety.

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

As always, our courses will continue to be PowerPoint free!

Objectives

  • Ensure a solid understanding of each step of the investigation process including:
  • How much information to gather and how to gather it
  • Involving patients, families and carers and embracing the duty of candour
  • How to conduct interviews with staff in a just culture
  • How to analyse the information gathered using timelines
  • Identification of factors requiring change
  • The importance of multi-disciplinary team involvement
  • Focus on good practice
  • Making proportionate and effective recommendations
  • Time management
  • Guidance on precision writing

Day 1

9.30am to 10.00am: Coffee and Registration

10.00am to 10.15am: People’s experiences of incident reporting and investigation are gathered and discussed. Overview of the investigation methodology.

10.15am to 10.45am: Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach and the importance of objectivity.

10.45am to 11.00am: Gathering information; a report is only as good as the information it is based on. Ensuring that information is gathered that will help investigators draft meaningful recommendations. Investigators in the past have tended to gather information to establish what happened forgetting to also gather information on why it happened; the importance of gathering human factors and ergonomic evidence.

11.00am to 11.15am: Coffee Break

11.15am to 11.30am: Case Study 1

11.30am to 12.30pm: Mapping the information using timelines.

12.30pm to 1.00pm: Lunch

1.00pm to 1.30pm: Critical and analytical thinking.

1.30pm to 2.30pm: Identifying barriers and safeguards; a ‘systems’ approach.

2.30pm to 2.45pm: Tea Break

2.45pm to 3.45pm: Focus on writing excellent recommendations, benchmarking, reasonable/measureable action plans and producing standardised reports. Example report format provided.

3.45pm to 4.00pm Conclusion

Day 2

9.30am to 10.00am: Coffee and Registration

10.00am to 10.15am: Overview of Day One learning and consolidation

10.15am to 11.00am: Witness statement writing; an improved standard of statement writing from staff will quicken the process of information gathering and analysis and make the incident investigation more effective.

11.00am to 11.30am: Coffee Break

11.30am to 12.30: Interview techniques; effective and supportive information gathering in a just culture.

12.30pm to 1.00pm: Lunch

1.00pm to 2.30pm: Case Study 2 (including interview role play)

2.30pm to 3.00pm: Tea Break

3.00pm to 4.00pm Feedback; staff, patient, family and carer involvement.

4.00pm Conclusion

 

Root Cause Analysis Training

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 Training for Beginners

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 Training

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 Training

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 Training

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 Training

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 Training – 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