|Organisation sharing the GOP||
Related practices from PaSQ database
|University College London NHS Hospitals Foundation Trust||
|Incident reporting and learning system
|Reporting and learning systems
|UCLH is a Large Acute NHS Foundation Trust located across 7 Main hospital sites with 19 clinical divisions. There are 3 Clinical Boards with significant devolved authority, who oversee the day to day operations of divisions.
7000 staff and provides a wide range of both acute and specialist services.
|The aims were to facilitate greater reporting, improved distribution of incident related intelligence at all management levels whilst also enabling greater localised learning and ownership of patient safety issues. The Trust replaced implemented an incident reporting system with an online electronic solution accessible to all staff.|
|Incident Reporting is a process applicable to all staff, therefore the system had to be carefully designed to combine ease of use, alongside all information analysis requirements for scrutiny and learning purposes.
A project group was established to ensure that the system was created with both of these elements in mind.
|Key methodology around electronic incident reporting includes:-
• Genuine engagement from those involved (including software company and staff)
• demonstrable willingness to flex plans based on feedback
• an ability to clearly describe the “future state” and benefits
• action to address gaps between current and future state.The running themes in terms of system implementation were to communicate / educate / change and challenge systems / manage welfare and expectations
In summary the system and its initial implementation project was given high visibility throughout the Trust. The Project Group were given regular updates from the Project team, and championed the concept of the DatixWeb system to make people across the Trust aware of the impending changes and their benefits. Trust wide emails were sent to inform staff of go live dates, posters were created to advertise this and distributed across sites, and a story was run on Insight. Staff were kept informed of developments at every potential stage.Following the implementation of the system, further training and information sessions continue to be delivered by the Datix Administrator as part of audit days and staff inductions.
|The implementation followed eighteen months of careful planning and preparation, to ensure that induction and training were undertaken by all staff who would be using the system from the first day it was put into effect.
The main project, from start up to go-live date took approximately 9 months. (see below)
|Implementation tools available|
|The Trust developed two e-learning packages based on Datango software which proved to be very successful. This e-learning enabled the rapid trust-wide implementation of the system from a single date, as opposed to any phased roll out.
Of the two training packages, one focused solely on the reporting process which all staff had to complete whilst the other addressed the incident review process for all identified handlers. The training packages incorporated screenshots.
|Main costs related to the creation of additional IT Infrastructure (server set up and system installation), project Management and the software purchasing/licensing. Some cost savings were made by the development and appointment of in-house Datix software experts
The project was delivered within budget and to agreed timescale.
|Method used to measure the results|
|Based on other experiences, it was identified that for most Trusts incident reporting levels decreased upon initial implementation as people adjusted to change. However, at UCLH, incident reporting dramatically increased as staff embraced online reporting. This acceptance of the new system was statistically apparent, as the number of incidents reported within the first 6 months doubled, compared to the same time the previous year. This increase in reporting has continued to rise significantly in the two years since implementation.|
|Following implementation the number of Incident Handlers was increased to cope with this higher reporting, further distributing local ownership and risk awareness. More specialised forms have been created since initial roll-out, as more people have become aware of the functionality of the system and understood its capabilities.
Local real time incident reporting has enabled Incident Handlers and managers to address incidents and any issues raised more quickly and easily, identifying immediate serious incidents, resulting in improved patient safety.
|Analysis of the results|
|The risk management team identifies patient trends and forwards reports to specific divisional groups in the Trust. Monthly risk reports are sent out to the divisions that enable the managers to drill down and create their own reports – such as the Falls Group or Tissue Viability nurses. Reports are also sent to the Patient Safety Steering Risk Committee and the Executive Board.
The trust has also seen encouraging decreases in the number of catastrophic/major incidents as a proportion of overall reporting rates. Although this cannot be directly attributed to the software, it is likely to played a significant part.
|Did you find implementation barriers?|
|Please describe implementation barriers|
|YES – Some Incident Handler and location data required to populate the database was delayed, as some divisions struggled to understand what information to provide within the agreed timescales.
After go live, some divisions complained that their location setup didn’t reflect the way they classified their areas, which needed additional work and resources to amend classifications to better reflect such locations.
|Describe the strategies used to overcome the barriers (If needed)|
|Significant challenges revolved around the engagement and involvement of the Tust’s ICT provider, with specific process requirements relating to upgrades/system changes sometimes proving difficult. Key links and relationships were created to help ease these difficulties, though some IT requirements remained time consuming.|
|Other information about the GOP that you would like to add (Link or attached document)|