Trust Board papers November 2012 - Barking Havering and ...

CQC Update Report
2012
reporting), with regular reporting
between HR and Clinical
Governance to ensure joint
management of patient safety
issues.
ASSESSING &
MONITORING
73. Ensure that it has systems in
place that allow effective
sharing and learning across the
whole organisation.
Existing guidance on learning from
serious incidents has been
reviewed and KPIs for
implementation have been
introduced. A bi‐monthly ‘Lessons
Learned’ group meets to generate
shared learning. This includes
using the content of Ombudsman
action plans to ensure learning
points are appropriately extracted
and shared. A rolling programme
of articles in the Link is supporting
learning. Directorate Boards now
review Serious Incident reports
and action plans to ensure timely
implementation.
Clinical Directors are sent details
of each relevant Serious Incident
and these are agenda items for
directorate clinical governance
meetings until they are responded
to in a suitable way.
This recommendation will only be
fully met when success can be
demonstrated over time. CQC and
other stakeholders not only expect
to see evidence that Serious
Incidents are being dealt with
internally, but also to see
commissioners and other external
organisations being informed
when relevant.
• All closed SIs are available on the Trust intranet.
• Clinical Directorate Governance leads review Sis and
other incidents for learning.
• Clinical Governance is a core topic on all monthly
meeting agendas.
Pam Strange
MET
BUSINESS
AS USUAL
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