CCG INCIDENT REPORTING AND MANAGEMENT USER GUIDE · CCG Incident Reporting and Management User Guide (1) Page 4 of 17 Official Complete the Incident Reporting Form as shown in figure

CCG Incident Reporting and Management User Guide (1) Page 1 of 17 Official

CCG INCIDENT REPORTING AND MANAGEMENT USER

GUIDE


Contents

1. How to Report an Incident .................................................................................... 3

2. Managing Routine Incidents ................................................................................. 6

3. Managing Clinical (Patient Safety) Incidents ........................................................ 8

4. How Managers, Manange Incidents on SIRMS ..................................................10

5. CCG Incident Assessment Matrix .......................................................................12

6. Incident Manager’s Checklist ..............................................................................14

7. Route Cause Analysis Guide ..............................................................................15

8. Contacts ..............................................................................................................16


1. How to Report an Incident

SIRMS can be accessed via the following link: https://sirms.necsu.nhs.uk Login to the SIRMS using your computer/windows login details shown in figure 1.

Figure 1: SIRMS login screen

Once logged in select “CCG/GP Reported Incident” from the top left Menu to take you to the incident form shown in Figure 2.

Figure 2: Incident Menu selection

https://sirms.necsu.nhs.uk/


Complete the Incident Reporting Form as shown in figure 3. The details of the person completing this form will be automatically populated and the orange highlighted fields are mandatory fields. Primary cause groups are categories of incidents, choosing one of these primary cause groups from the drop down will affect the primary cause and secondary cause choices in the next fields.

Figure 3: Incident Form

When you have filled in the form you can save for later or click next to continue.

Figure 4: Navigation Buttons

The next page of the form is to provide details of “Where the Incident Happened” and the organisations involved in the incident.


If the organisation involved is not listed, you can add it in the ‘Location Details’ section.

Figure 5: Incident form

Notify and discuss with your line

manager of any incidents that you are

involved in. Enter their surname in this

section, if their name does not appear

contact [email protected]

or ring 0191 374 4157

mailto:[email protected]


2. Managing Routine Incidents

All CCG staff (permanent, fixed term and contractors) have a duty to report the incidents that they are involved in or witness. Staff Members are instructed to use the CCG/GP incident reporting page on SIRMS to report these incidents. When recording the incident on SIRMS you will be asked to score the incident. Refer to Section 5 incident risk matrix.

2.1 Managing an incident on SIRMS All incidents must be managed on SIRMS. The CCG Corporate Investigating Manager will be notified of the incident via SIRMS and will sign post the incident to a CCG Appointed Investigating Incident Officer who will be responsible for its management. The CCG Appointed Investigating Incident Officer must consider if it is necessary to carry out a route cause analysis of the incident. Refer to Section 7; Root Cause Analysis Guide. The CCG Appointed Investigating Incident Officer will provide feedback to the reporter of the incident.

2.1.1 Incidents score 1-3 Those incidents with a score of 1 -3 on the incident risk matrix are not classed as serious but still must be acknowledged and reviewed within 24 hours on SIRMS.

2.1.2 Serious Incidents Any incident with an incident score of 4 (major) or 5 (catastrophic) should still be recorded as an incident on SIRMS. SIRMS will automatically notify the appropriate CCG Corporate Investigating Manager, Chief Finance Officer or Chief Officer (or equivalent) and relevant CSU specialist (contact details of specialist can be found in section 8).

2.2 CCG Timeline for managing and closing incidents The CCG Appointed Investigating Incident Officer of the incident will have allocated a colour coded impact rating when managing their incidents on SIRMS. The colour indicates the timeline for managing the incident and the process for closing the incident down; as outlined in table 1.

For incidents graded 1-3; the CCG Appointed Incident Investigating Officer submits the “Managers form” with details of the underlying (root) cause and outcome from the incident, the incident will be given the status of ‘Completed by Manager’. The CCG Corporate Investigating Manager is automatically notified and will review the incident (and agreed recommendations and remedial actions). The CCG Corporate Investigating Manager will notify the CSU Governance team that the incident status can be updated to ‘Fully Complete’ (if appropriate) in the SIRMs database. The incident will be then be archived on SIRMS by the CSU Governance team.


1 Negligible/no harm Incident to be noted and closed off within 5 days by the CCG Appointed Incident Investigating Officer.

2 Low risk CCG Appointed Incident Investigating Officer to manage and close off the incident within 5 days.

3 Medium risk - The CCG Appointed Incident Investigating Officer will manage and close off the incident within 5 days.

4

High risk Once recorded these incident must be referred immediately to the Chief Finance Officer or Chief Officer (or equivalent), CCG Corporate Investigating Manager and a CSU Specialist Officer. A management response is required as soon as possible within a 24 hour period.

The Chief Finance Officer or Chief Officer (or equivalent), to close off the incident within 1

month. If the close off target is not met an interim report of progress needs to be submitted to the CCG Corporate Investigating Manager.

5

Catastrophic Once recorded these incident must be referred immediately to the Chief Finance Officer or Chief Officer (or equivalent),, CCG Corporate Investigating Manager and a CSU Specialist Officer. A management response is required as soon as possible within a 24 hour period. The Chief Finance Officer or Chief Officer (or equivalent), to close off the incident within 1 month. (If the close off target is not met an interim report of progress needs to be submitted to the CCG Corporate Investigating Manager.

Table 1: CCG Corporate Business Incident Impact Score, Grading, Responsibility and Timeframes

As outlined in section 2.1.2 of the User Guide any incident with an incident score of 4 (major) or 5 (catastrophic) should still be recorded as an incident on SIRMS. SIRMS will automatically notify the appropriate CCG Corporate Investigating Manager, Chief Finance Officer or Chief Officer (or equivalent), and relevant CSU specialist (contact details of specialist can be found in section 8).

2.3 Specialism Incidents 2.3.1 Property Services Any Incidents relating to defects or issues within the building MUST be reported to the relevant NHS Property Services Help Desk immediately, as well as on SIRMS. Refer to section 8 for contact.

2.3.2 Data Security and Protection Incidents Any Incidents identified with an impact score of 4 (High risk) and 5 (Catastrophic) relating to Data Security and Protection should be highlighted to the CSU Information Governance team (See appendix 8 for contact information) 2.3.3 Health and Safety Incidents Any Incidents identified with an impact score of 4 (High risk) and 5 (Catastrophic) relating to Health and Safety should be highlighted to the CSU Health and Safety team (See appendix 8 for contact information) 2.3.4 Information Technology

Any Incidents identified with an impact score of 4 (High risk) and 5 (Catastrophic) relating to Information Technology should be reported on SIRMs and also reported to the ICT Service desk (See appendix 8 for contact information).


3. Managing Clinical (Patient Safety) Incidents

3.1 Record the Incident

Clinical Quality / Patient Safety incidents can be recorded by CCG staff when they become aware of service quality, delivery or contracting issue in one of their commissioned providers. Along with similar intelligence recorded by the CCG Member Practices, these incidents can help identify areas for improvement in quality, performance and commissioning. All staff (permanent, fixed term and contractors) should report any clinical quality / patient safety incidents they are aware of. To report these staff should use the CCG/GP reporting an incident page of SIRMS which can be accessed via the following link https://sirms.necsu.nhs.uk

3.2 Determine if the Clinical Quality / Patient Safety Incident is a Serious Incident

The CSU clinical quality team monitor and review all clinical quality / patient safety incidents to determine the likely impact score of the incident. An incident with a score of 4 to 5 on the incident impact assessment scale will be further assessed to determine whether it meets the national guidance criteria as a reportable Serious Incident which will require external reporting on the StEIS system. Serious Incidents are outlined in the national guidance and the CCG Serious Incident Management policy. Serious Incidents can be clinical or non-clinical in nature. The CSU Clinical Quality team will liaise with the CCG quality and/or governance lead to report the serious incident onto StEIS on behalf of the CCG. The CCG Corporate Investigating Manager and the CSU Clinical Quality team will then agree if the CCG serious incident policy needs to be invoked.

3.3 Managing a Clinical Quality / Patient Safety Incident on SIRMS

All clinical quality / patient safety incidents reported on SIRMS will be managed by the CSU Clinical Quality team covering the CCG area from which the incident was reported. The CSU Clinical Quality team will manage the incident on SIRMS via the Managers form and will:

1. Review the content and quality of the information entered to ensure the correct incident categories etc. have been completed;

2. Assess the impact of the incident and score it accordingly;

1-3 & 6 Identify any themes and trends across similar incident types and share incident at regular monthly meetings with Providers in thematic reports;

4-5: Request NHS Number or other patient identifiable data from reporter (if relevant) and request individual investigation carried out within 2 weeks.

Provide feedback to the reporter on actions taken on the incident.

3.4 Advise the reporter

The CSU Clinical Quality team will provide feedback to the reporter and will:

1. Thank the reporter for reporting the issue; 2. Provide a description of any changes made to form and why they were made; 3. Request that they or their manager complete the sections on Actions, Root Causes and

Outcomes where relevant; 4. Provide a brief description of what will happen with the incident (e.g. included in themes &

trend or specific response requested from Trust etc.)


http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf



3.5 Timeline for managing and closing Clinical Quality / Patient Safety incidents As outlined in section 2.2 of the User Guide, reporters will have allocated a colour coded impact rating when reporting their incidents on SIRMS. The impact rating gives a recommended indication of the timeline for managing the incident and the expected action for management. Managers can review this rating based on their understanding of the incident.

1 Negligible/no harm Incident to be noted and closed off within 5 days by the CSU Clinical Quality team.

2,6,

Low risk CSU Clinical Quality team to review incident within 5 working days and share with Provider in monthly reports. Incident themes and trends to be shared at internal CCG quality group and Provider QRG.

3

Medium risk CSU Clinical Quality team to review incident within 5 working days and share with Provider in monthly reports. Incident themes and trends to be shared at internal CCG quality group and Provider QRG.

4

High risk The incident should be reviewed as soon as possible, ideally within 48 hours, of reporting. CCG Head of Quality & Safety (or equivalent) will work with the CSU Clinical Quality team to request an initial response from the provider within 2 weeks and a subsequent full response within 4 weeks. All incidents of this grade will be monitored through the internal CCG quality group and Provider QRG. Closure of the incident will be finally ratified by the CCG internal quality group.

5

Catastrophic Once recorded these incidents should be referred immediately to the CCG Head of Quality & Safety (or equivalent) and the CSU Senior Clinical Quality Programme Lead. Initial review and response is required as soon as possible within a 24hour period. CCG Head of Quality & Safety (or equivalent) will work with the CSU Clinical Quality team to request an initial response from the provider within 2 weeks and a subsequent full response within 4 weeks. All incidents of this grade will be monitored through the internal CCG quality group and Provider QRG. Closure of the incident will be finally ratified by the CCG internal quality group.

Table 2: CCG Clinical Quality / Patient Safety Incident Impact Score, Grading, Responsibility and Timeframes

3.6 CSU Clinical Quality Team will close the incident on SIRMS

Once recommendations and remedial actions are in place and the incident has been closed down by the internal CCG Quality Group. A summary of incident themes, trends and outcomes will be provided in the regular clinical quality reports to the CCG. The CSU Clinical Quality team will then ‘fully complete’ / close the incident in SIRMs.


4. How Managers, Manange Incidents on SIRMS

Managers access SIRMS, as outlined in section 2 of the User Guide.

Once logged in select “Manage Incidents” from the top left Menu to take you to the incident form

shown in Figure 6.

Figure 6: Incident Menu

Once logged in you will see the incidents reported / for managing in a list format, as shown in figure 7. From here you can click on the incident that needs investigating.

Figure 7: Managers Incident List

When the Incident in your list is selected an Incident Summary will appear on the right, shown in figure

8.

Figure 8: Incident Summary

The incident form will appear as shown in figures 3 and 5 along with a Managers section, as shown in figure 9 for the Manager to review and update.

To manage the incident and form

click on the Managers Form

Button located at the top of the

Summary


Figure 9: Managers Review Section

If the incident has been resolved the CCG Appointed Incident Investigating Officer can “close” the incident. This will ensure the incident status is now ‘Completed by Manager’. As outlined in section 2.2 incidents graded 1-3; the CCG Appointed Incident Investigating Officer submits the “Managers form” with details of the underlying (root) cause and outcome from the incident, the incident will be given the status of ‘Completed by Manager’. The CCG Corporate Investigating Manager is automatically notified and will review the incident (and agreed recommendations and remedial actions). The CCG Corporate Investigating Manager will notify the CSU Governance team that the incident status can be updated to ‘Fully Complete’ (if appropriate) in the SIRMs database. The incident will be then be archived on SIRMS by the CSU Governance team


When the CCG Appointed Incident Investigating Officer completes the form (Figure 9) an automatic email will be sent to the member of staff that reported the incident, as shown in figure 10.

Figure 10: Automatic Notification Email

5. CCG Incident Assessment Matrix

A risk-based approach is used to link incidents to the risk management framework. The use of an incident grading system will help to assess the level of risk attributed to an incident, its seriousness and the level of investigation or analysis to be undertaken. In some cases the outcome of the incident is such that it is immediately obvious that the incident is serious or significant When assessing the risk of an incident, reporters should use the risk matrix outlined below

5.1 Assessing the Incident

Step 1: Determine the consequence score of Incidents

From the submitted incident make a note of the cause group and use the corresponding tables (Tables 3.1 – 3.5) below to assess the consequence rating, the number is given at the top of the column. The consequence score will either be:

Negligible,

Minor,

Moderate,

Major

Or catastrophic.

When scoring the consequence you are assessing either:

The consequence of the incident that has occurred

Or the likely consequence of a near miss should the incident have occurred

NOTE

Any incident with a consequence score of 4 (major) or 5 (catastrophic) needs to be referred immediately to the responsible Chief Finance Officer or Chief Officer (or equivalent), and the CCG Corporate Investigating Manager. An immediate management response is required. The incident needs to be recorded on SIRMS. Once recorded on SIRMS the above contacts will be notified automatically.


Consequence and Likelihood Scoring Matrix Operational, Reputational and Financial Scoring Matrix

Impact score (consequence/severity levels) and examples of descriptors

1 2 3 4 5

Descriptor Negligible (very low)

Minor (low) Moderate (low) Moderate (high) High

Operational Minor reduction in quality of treatment or service. No or minimal effect for patients / customers

Single failure to meet national standards of quality of treatment or service. Low effect for small numbers of patients / customers

Repeated failure to meet national standards of quality of treatment or service. Moderate effect for multiple patients / customers if unresolved.

Ongoing non-compliance with national standards of quality of treatment or service. Significant effect for numerous patients / customers if unresolved.

Gross failure to meet national standards with totally unacceptable levels of quality of treatment or service. Very significant effect for a large number of patients if unresolved.

Reputational Not relevant to mandate priorities. No adverse media coverage. Recognition from the public.

Minor impact on achieving mandate priorities. Low level of adverse media coverage. Small amount of negative public interest.

Moderate impact on achieving mandate priorities. Moderate amount of adverse media coverage. Moderate amount of negative public interest.

High impact on achieving mandate priorities. High level of adverse media coverage. Negative impact on public confidence.

Mandate priorities will not be achieved. National adverse media coverage. Total loss of patient / customer confidence.

Financial Small loss where risk of claim is remote

Loss of 0.1% - 0.25% of budget where claims are less than £10,000

Loss of 0.25% - 0.5% of budget where claims are between £10,000 - £100,000

Uncertain delivery of key objective / loss of 0.5% - 1.0% of budget. Claim(s) between £100,000 and £1 million. Purchasers failing to pay on time.

Non-delivery of key objective. Loss of more 1% of budget. Failure to meet specification / slippage. Loss of contract / payment by results. Claim(s) of more than £1 million.

Table 3.1 Operational, Reputational and Financial Scoring Matrix

Likelihood score 1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost certain

Frequency How often might it/does it happen

This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting issue

Will undoubtedly happen/recur, possibly frequently

Table 3/2: Likelihood Scoring Matrix


Step 2 - Timeline for Managing Incidents

1 Negligible/no harm Incident to be noted and closed off within 5 days by the CCG Appointed Incident Investigating Officer.

2 Low risk CCG Appointed Incident Investigating Officer to manage and close off the incident within 5 days.

3 Medium risk - The CCG Appointed Incident Investigating Officer will manage and close off the incident within 5 days.

4

High risk Once recorded these incident must be referred immediately to the Chief Finance Officer or Chief Officer (or equivalent), CCG Corporate Investigating Manager and a CSU Specialist Officer. A management response is required as soon as possible within a 24 hour period. The Chief Finance Officer or Chief Officer (or equivalent), to close off the incident within 1 month. If the close off target is not met an interim report of progress needs to be submitted to the CCG Corporate Investigating Manager.

5

Catastrophic Once recorded these incident must be referred immediately to the Chief Finance Officer or Chief Officer (or equivalent),, CCG Corporate Investigating Manager and a CSU Specialist Officer. A management response is required as soon as possible within a 24 hour period. The Chief Finance Officer or Chief Officer (or equivalent), to close off the incident within 1 month. (If the close off target is not met an interim report of progress needs to be submitted to the CCG Corporate Investigating Manager.

6. Incident Manager’s Checklist It is important that lessons are learned from incidents which will help drive up standards across the organisation. 1. Do you know exactly what happened?

Talk to the person/people affected

Ensure you know exactly where and when the incident happened – this will be relevant to the investigation

If the incident involved equipment or furniture ensure these are retained but not used.

Offer support and reassurance 2. Has the incident led to a member of staff being absent from work?

If a staff member is absent from work for more than 7 days as a result of an incident that happened at work, the organisation must report this to the HSE through RIDDOR.

Inform Senior Governance Officer (Health & Safety, Fire) who will make the RIDDOR report. 3. Have you identified the cause of the incident?

Incidents may be caused by training need

It might be part of a wider issue

Ensure you have gathered sufficient evidence and documentation 4. Is a complaint likely to result from the incident?

Anticipating that a complaint might be made, apologising and explaining what steps you are going to take to correct a situation will often prevent a complaint from being made.

5. Is the incident likely to lead to litigation?

All the information about the incident will be required in the event of a claim being made after an incident, it is therefore vital to ensure that every step taken has been fully documented and all documentation has been uploaded to SIRMS.


6. Have you put any immediate remedial measures in place?

Take steps to avoid a repeat of the incident

Ensure you have evidence and documentation of the remedial measures 7. Are there any longer-term actions required?

Training and awareness raising

HR: recruitment, performance review, support

Development of policy/procedure

Local action plan

Contract negotiation/renegotiation

Ensure you have evidence and documentation 8. Rate the incident by its consequence and likelihood of reoccurrence. 9. Provide feedback to the person/people involved in the incident.

Keep people informed of progress

Offer reassurance

Ensure you have evidence and documentation 10. Are you satisfied that all actions are complete?

Upload all relevant documents to SIRMS

Save and close

7. Route Cause Analysis Guide

7.1 What is it and how can it help me? By repeatedly asking the question ‘why?' (use five as a rule of thumb), you can peel away the layers of an issue, just like the layers of an onion, which can lead you to the root cause of a problem. The reason for a problem can often lead into another question; you may need to ask the question fewer or more than five times before you get to the origin of a problem. The real key is to avoid assumptions and logic traps and encourage the team to keep drilling down to the real root cause.

7.2 When does it work best? By quickly identifying the source of an issue or problem, you can focus resources in the correct areas

and ensure that you are tackling the true cause of the issue, not just its symptoms.

7.3 How to use it

7.3.1 How to complete the five whys

1. Write down the specific problem. Writing it down helps you formalise the problem and describe it accurately. It also helps a team focus on the same problem

2. Use brainstorming to ask why the problem occurs then, write the answer down below 3. If this answer doesn't identify the source of the problem, ask ‘why?' again and write that

answer down 4. Loop back to step three until the team agrees that they have identified the problem's root

cause. Again, this may take fewer or more than five ‘whys?'

7.3.2 Why use the five whys?

Helps you to identify the root causes of a problem

Helps you to determine the relationship between different root causes of a problem

It is one of the simplest analysis tools as it’s easy to complete without statistical analysis

It is easy to learn and apply


7.3.3 Five whys and cause and effect diagrams The five whys can either be used independently or as a part of a cause and effect diagram (fishbone diagram). The diagram helps you explore all potential or real causes which result in a failure or problem. Once you have established all the inputs on the cause and effect diagram, you can use the five whys technique to drill down to the root causes. Tips

Moving into 'fix-it' mode too quickly might mean dealing with symptoms but leaving the problem unresolved, so use the five whys to ensure that the cause of the problem is being addressed

If you don't ask the right questions, you don't get the right answers. A question asked in the right way often points to its own answer

Example of Five Whys Why? Complaint about dissatisfaction with a service to a customer. Why? Reports they had needed were not delivered in a timely manner. Why? SLA stated a particular date to deliver the reports. Why? The customer wanted reports outside this schedule. Why? There was no standard process for making changes to schedules and the contact was absent from work so the customer didn’t know who to contact.

The root cause – There was no clear process for making routine change requests and no alternative contact detail. Solution/ Lessons learned – A standard form for submitting change requests has been created and the new process has been shared with both organisations and all relevant staff. A generic email address has been created (and this is now standard across all the team’s processes) and this will be constantly monitored by several staff.

7.4 Background The five whys originated within Toyota as they developed their manufacturing methodologies. It forms a critical component of their problem solving training and is part of the induction into the Toyota production system. It is now also used within Six Sigma. Very often, the answer to the first ‘why?' will prompt another ‘why?' The answer to the second ‘why?' will then prompt another and so on; hence the name, the five whys strategy.

Acknowledgements / sources Six Sigma - Determining the Root Cause: 5 Whys, The Improvement Network © Copyright NHS Institute for Innovation and Improvement 2008 © Copyright NHS Institute for Innovation and Improvement 2006-2013

8. Contacts

8.1 CSU Corporate Business CCG Account Directors (for incidents)

Cumbria & Northumberland CCGs – Lisa Howe [email protected] 07826943703

Durham - (Darlington, North Durham & DDES CCGs) Anne Greenley [email protected]

South Tees CCG – Tracey Hickman - [email protected]

Newcastle Gateshead Alliance CCGs & HaST CCG - Khalid Azam: [email protected]

Sunderland, South Tyneside, North Tyneside CCGs - Ailsa Nokes: [email protected]







8.2 CSU Incident Specialist

Information Governance: [email protected]

Information Technology: 0300 555 0340 (www.servicedesk.necsu.nhs.uk)

Health and Safety: [email protected]

North East and North Central: 0191 3371593 [email protected]

Patient Safety Incidents: [email protected] 8.3 General Incident Contacts

SIRMS queries: [email protected]


http://www.servicedesk.necsu.nhs.uk/





Documents

CCG INCIDENT REPORTING AND MANAGEMENT USER GUIDE · CCG Incident Reporting and Management User Guide (1) Page 4 of 17 Official Complete the Incident Reporting Form as shown in figure