Launch of Incident Management Framework (2020) - Event Details and Insights

 
Welcome to the launch of the Incident Management
Framework (2020). The event will start shortly.
Should you have any questions or comments, please use
chat box and select all attendees when sending your
question / comments.
Should you lose connection or if your sound quality is poor,
you may wish to mute your computer audio and dial in by
phone.
Dial in details 
for the event are
01 5260058
Access Code: 137 396 9504#
Note
: this session is being recorded
 
Message from the CEO
 
Format of Session
 
Process undertaken to revise the IMF
 
Lessons from practice
 
Key changes in the 2020 version
 
Background to the revision
 
HSE Incident Management
Framework launched in 2018
 
Commitment to review after a
year 
to gain an understanding
of its use in practice and to
identify any areas where
additional clarity or guidance
may be required
 
 
Review Process
 
Online questionnaires, meetings, workshops
and focus groups.
Alignment with National Patient Safety
Strategy and revisions to the HSEs Open
Disclosure policy.
Consultation with QPS advisors
Sign off by HSE Safety and Quality Committee
and the EMT (Sept 2020).
 
Lessons from
practice
 
Lesson 1 . Learning to talk about error
before it happens
 
To develop a culture of
safety we must first
create a culture of
psychological safety
where talking about
safety is a normal part of
the way we seek to
improve services.
 
Lesson 2. Before you start
 
When 
and when
not
 to use the
Incident
Management
Framework
 
Lesson 3: Lean In
 
Supporting service users and
families starts from get go and
continues.
 
Imagine
 
You are that staff member
You are that service
user/relevant person
 
How would you feel?
How would you want to be
responded to?
 
Lesson 4 – Trust is critical
 
“What I’ve found through
research is that trust is built
in very small moments…’
Trust is the stacking and
layering of [these] small
moments and reciprocal
vulnerability over time. Trust
and vulnerability grow
together, and to betray one
is to destroy both.”
Brené Browne
 
Lesson 5. Verifiable decision making
 
The IMF at its core is a
decision making framework
 
 
Decisions must be based on
evidence
 
 
The evidence upon which
decisions are made should be
documented and verifiable
 
Lesson 6. It’s ok to decide that no
further review is required
 
Decisions must be
Based on a preliminary
assessment and
supported by a reason
Must be communicated
formally to service
user/relevant person
and staff
Must be ratified by the
QPS or equivalent
committee
 
Lesson 7. If you proceed to further
review, do so fairly
 
Not to do so risks
 
Perception of a blame culture
 
Loss of staff and service user
confidence – not just in relation to
this case
 
Collapse of the review process
 
 
Lesson 8. The blue thread rule
 
Recommendations should
flow from the data
gathered, its analysis, the
findings and the factors that
contributed to them.
 
Lesson 9. Recommendations versus
Learning
 
Recommendations are specific to
the context in which the incident
occurred.
 
Learning is something that other
areas/services may consider as
applying to them.
 
Reports may identify both.
 
Lesson 10. Keep reports simple and
accessible
 
Long complex reports are
often counter- productive.
 
Though your report will be
based on the analysis of a
lot of evidence it does not
all need to be included in
the report.
 
Remember your audiences
 
 
Lesson 11. Make the change
 
Having identified what needs to
change to reduce the risk of
recurrence – Make the change!
 
Link actions where possible into
existing improvement planning
 
Lesson 12. Supporting Practice
 
Key Changes
 
The Incident Management Framework (IMF)
 
The IMF Guidance
 
Documents supporting the IMF and Guidance
 
Key areas of change IMF
 
Definitions
  - aligned with related legislative  and
policy changes
Policy statement 
- more explicit links made to the
Open Disclosure Policy
Roles and Responsibilities 
- more explicit reference to
the role of the SAO and LAO
Governance arrangements 
- Reference to the
availability of the IMF audit tool for self-assessment of
compliance
Service User Liaison Person
 - now changed to
Designated Support Person (in line with PS Bill)
Term Key Causal Factors  - 
to changed to Findings
Comprehensive Review 
– now one approach
Requirements for management of 
Multi- Incident 
and
Cross Service incidents 
have also been revised
 
Key areas of change IMF Guidance
 
Definitions
  - aligned with related legislative  and
policy changes
Creating a Just Culture –
 
New Section
This section replaces the Incident Decision Tree
Guidance
SIMT – 
role in oversight of all Cat 1 incidents and on
notification of a new Cat 1 incident
Preliminary Assessment Form
  - This form has been
amended based on feedback
Approaches to Incident Review  - 
Comprehensive
approach revised
Systems Analysis Guidance  - 
incorporated into
overall guidance. A number of tools to support
analysis have also been included.
Developing Recommendations 
– rewritten based on
the output of a group convened to review the
process of developing recommendations
Retention of Records relating to an incident review
 -
NEW Section
 
Other areas of change
 
All supporting documents and guidance on website reviewed in
the context of IMF and Guidance 2020
 
Service User Info Leaflet – this now includes SU consents for
reviewers access to  the healthcare record, participation in the
review process, inclusion of the review report on NIMS and sharing
of lessons learnt with other services.
 
Staff Info Leaflet – this rather than just relating to Systems Analysis
has been reframed in the context of incident review
 
PAF form – amended per feedback and revisions to the process
 
Application for expert nomination from the Forum – aligned to
new requirements of review process e.g. reference to Review
Panel and Review Team removed
NOTE: 
Access supporting documentation from
https://www.hse.ie/eng/about/qavd/incident-management/
 rather than
rely on saved versions which may be out of date
 
Conclusion
 
 Thank you all for your attendance today and to the many
of you who have contributed to the IMF 2020.
 
Hard copies of the documents and leaflets have been
delivered to each HG/CHO/National Services for onward
distribution.
Please visit the HSE’s Incident Management Webpage for
more resources.
 
https://www.hse.ie/eng/about/qavd/incident-
management/
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Welcome to the launch of the Incident Management Framework 2020 event. Discover the format, background, review process, lessons learned, and key changes. Gain insights into creating a culture of safety, knowing when to use the framework, and the importance of trust in incident management. Engage in discussions, ask questions, and be part of this informative session. Stay connected and learn how to improve service quality and safety.


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  1. Welcome to the launch of the Incident Management Framework (2020). The event will start shortly. Should you have any questions or comments, please use chat box and select all attendees when sending your question / comments. Should you lose connection or if your sound quality is poor, you may wish to mute your computer audio and dial in by phone. Dial in details for the event are 01 5260058 Access Code: 137 396 9504# Note: this session is being recorded

  2. Message from the CEO

  3. Format of Session Process undertaken to revise the IMF Lessons from practice Key changes in the 2020 version

  4. Background to the revision HSE Incident Management Framework launched in 2018 Commitment to review after a year to gain an understanding of its use in practice and to identify any areas where additional clarity or guidance may be required

  5. Review Process Online questionnaires, meetings, workshops and focus groups. Alignment with National Patient Safety Strategy and revisions to the HSEs Open Disclosure policy. Consultation with QPS advisors Sign off by HSE Safety and Quality Committee and the EMT (Sept 2020).

  6. Lessons from practice

  7. Lesson 1 . Learning to talk about error before it happens To develop a culture of safety we must first create a culture of psychological safety where talking about safety is a normal part of the way we seek to improve services.

  8. Lesson 2. Before you start When and when not to use the Incident Management Framework

  9. Lesson 3: Lean In Supporting service users and families starts from get go and continues. Imagine You are that staff member You are that service user/relevant person How would you feel? How would you want to be responded to?

  10. Lesson 4 Trust is critical What I ve found through research is that trust is built in very small moments Trust is the stacking and layering of [these] small moments and reciprocal vulnerability over time. Trust and vulnerability grow together, and to betray one is to destroy both. Bren Browne

  11. Lesson 5. Verifiable decision making The IMF at its core is a decision making framework Decisions must be based on evidence The evidence upon which decisions are made should be documented and verifiable

  12. Lesson 6. Its ok to decide that no further review is required Decisions must be Based on a preliminary assessment and supported by a reason Must be communicated formally to service user/relevant person and staff Must be ratified by the QPS or equivalent committee

  13. Lesson 7. If you proceed to further review, do so fairly Not to do so risks Perception of a blame culture Loss of staff and service user confidence not just in relation to this case Collapse of the review process

  14. Lesson 8. The blue thread rule Data Recommendations should flow from the data gathered, its analysis, the findings and the factors that contributed to them. Analysis Findings Contrib Factors Recs

  15. Lesson 9. Recommendations versus Learning Recommendations are specific to the context in which the incident occurred. Learning is something that other areas/services may consider as applying to them. Reports may identify both.

  16. Lesson 10. Keep reports simple and accessible Long complex reports are often counter- productive. Though your report will be based on the analysis of a lot of evidence it does not all need to be included in the report. Remember your audiences

  17. Lesson 11. Make the change Having identified what needs to change to reduce the risk of recurrence Make the change! Link actions where possible into existing improvement planning

  18. Lesson 12. Supporting Practice

  19. Key Changes The Incident Management Framework (IMF) The IMF Guidance Documents supporting the IMF and Guidance

  20. Key areas of change IMF Definitions - aligned with related legislative and policy changes Policy statement - more explicit links made to the Open Disclosure Policy Roles and Responsibilities - more explicit reference to the role of the SAO and LAO Governance arrangements - Reference to the availability of the IMF audit tool for self-assessment of compliance Service User Liaison Person - now changed to Designated Support Person (in line with PS Bill) Term Key Causal Factors - to changed to Findings Comprehensive Review now one approach Requirements for management of Multi- Incident and Cross Service incidents have also been revised

  21. Key areas of change IMF Guidance Definitions - aligned with related legislative and policy changes Creating a Just Culture New Section This section replaces the Incident Decision Tree Guidance SIMT role in oversight of all Cat 1 incidents and on notification of a new Cat 1 incident Preliminary Assessment Form - This form has been amended based on feedback Approaches to Incident Review - Comprehensive approach revised Systems Analysis Guidance - incorporated into overall guidance. A number of tools to support analysis have also been included. Developing Recommendations rewritten based on the output of a group convened to review the process of developing recommendations Retention of Records relating to an incident review - NEW Section

  22. Other areas of change All supporting documents and guidance on website reviewed in the context of IMF and Guidance 2020 Service User Info Leaflet this now includes SU consents for reviewers access to the healthcare record, participation in the review process, inclusion of the review report on NIMS and sharing of lessons learnt with other services. Staff Info Leaflet this rather than just relating to Systems Analysis has been reframed in the context of incident review PAF form amended per feedback and revisions to the process Application for expert nomination from the Forum aligned to new requirements of review process e.g. reference to Review Panel and Review Team removed NOTE: Access supporting documentation from https://www.hse.ie/eng/about/qavd/incident-management/ rather than rely on saved versions which may be out of date

  23. Conclusion Thank you all for your attendance today and to the many of you who have contributed to the IMF 2020. Hard copies of the documents and leaflets have been delivered to each HG/CHO/National Services for onward distribution. Please visit the HSE s Incident Management Webpage for more resources. https://www.hse.ie/eng/about/qavd/incident- management/

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