RECENT PROJECTS
Testimonials | Consulting Services | Recent Projects
Our consultants have worked on a range of projects. Examples are summarised below:
Review of Historic Serious Incidents:
Led a major independent review of investigations into serious incidents of a former NHS Trust
Our consultants were appointed by an NHS regulator to evaluate the efficacy of investigations into several years of historic serious incidents. Expert clinicians reviewed the incident documentation and outputs were quantified.
OUTCOME: Clinician insight and observations were themed into clinical or incident management learning points to form a quality improvement action plan. Findings confirmed some known issues already being addressed, while also identifying opportunities to improve learning from serious incidents through specialist support and training.
Supporting Second Victims:
Creating a process for individuals and teams to be supported following an adverse incident
Following an incident, organisations need to understand what happened, ensure remedial care is delivered to the harmed patient and mitigate to prevent recurrence of similar incidents. However sometimes clinicians involved in an incident can be overlooked, even though they can often be the second victims. Our consultants worked with a corporate incident management function to address these issues.
OUTCOME: A policy and a post incident protocol was established and promoted to ensure staff were offered support in immediate terms, as well as access to other support such as counselling.
Interdisciplinary Working:
Risk of patient harm from internal ward transfers
A review of data showed an increase in adverse incidents following the transfer of patients between units within a hospital setting. Initial, separate workshops with medical and nursing teams found that patients were being transferred without consultation with the patient’s lead clinician or considering the risk of the transfer to the patient.
OUTCOME: A subsequent joint workshop created wider awareness of the risk (to patients and the organisation) and a process of medical consultation prior to transfer was established. Additionally, a doctor was appointed to the patient transfer committee. Latterly a reduction in patient post transfer incidents was reported.
Risk and Accountability:
Consultation with a newly acquired service
A client acquired a new service, with more than 350 employees. As part of a wider transition process our consultants undertook a series of small workshops with more than 250 of the new employees to identify risks to delivering safe care and to empower staff to report risks and incidents. Participants suggested improvement activity and debated personal and professional accountability and responsibility.
OUTCOME: Risk became a unifying platform and staff from different localities and professional groups had greater empathy for and understanding of the issues affecting other teams. Incident reporting subsequently increased and a specific incident type noticeably reduced. Workshop evaluation from more than 250 participants rated: 57% Excellent and 37% Very Good
Clinicians Managing Risk:
Using Design Thinking processes to engage frontline staff to improve patient safety
A patient seriously self-harmed in a unit where patients were assessed, risk managed and encouraged to live independently. Clinicians and carers were deeply affected by the incident. Several team facilitation sessions were held to explore factors leading to the incident. Staff felt supported and openly shared learning points and suggested potential mitigations.
OUTCOME: Shortly following the initial session the incident team and ward management agreed with unit residents to introduce a search policy to prevent potentially dangerous items being brought on to the premises. Two years after this incident the team/service were rated Outstanding from their CQC inspection.
Serious Incident Team Facilitation:
Led a clinical team engagement following an inpatient self-harm fatality
Learning from deaths is important but difficult work. Our consultants worked with two separate clinical teams involved with a patient’s care. Combined, facilitated sessions produced broad and deep context, enabling incident investigators to more rapidly understand what happened and the key factors leading to the incident.
OUTCOME: This approach enabled all clinicians involved to actively learn from the incident and not just the investigators. The case was proactively shared with the wider service through learning events.
Learning from Deaths:
Structured four-hour learning workshop based on the RCA of an inpatient death
A client wanted to broaden the learning obtained from the death of a patient. Our consultants created engaging and thought-provoking content based on the investigation report for workshops with multidisciplinary staff and teams.
OUTCOME: Participants were actively engaged in the case. Feedback was so positive the workshop was recommended for wider rollout.
Complex Patient History:
Learning from an investigation into an inpatient death
Our consultants were appointed to review investigation reports into a cluster of similar deaths. A range of recurring themes was identified. Due to the complexity of a patient’s history our consultants created a graphical representation of key events over time.
OUTCOME: The incident mapping enabled the visualisation of the patient’s self-harm events by frequency and severity and to pinpoint the changes in self-harm methods.
Learning from Incidents:
Engage consultant medics in sharing patient safety incidents
Learning material was based on recent incidents documents, including 72-hour reports and RCA reports. Participants were encouraged to contribute insight and challenge care and incident management.
OUTCOME: Consultants requested greater access to incident data for ongoing learning as well as increased opportunities to be involved in the investigation process and for findings to be shared.