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In 2015 NHS England introduced the updated Serious Incident (SI) Framework. An additional ‘Frequently Asked Questions’ document was also produced, with an updated version of the ‘FAQ’s’ being published in 2016.

As part of the FAQ, clarity was provided regarding what training was recommended in order to complete an investigation.

The document states:

“For staff leading a Root Cause Analysis [RCA], Patient Safety Investigation this should include:

A 2-day training course which offers a practical element to the training, in particular the analysis section”.

We utilised professional actors on day 2 to assist with the scenarios regarding Duty of Candour training

Since the termination of the National Patient Safety Agency who had originally provided both the RCA/Being Open (Pre 2014 Duty of Candour Legislation) training resources and tools, it was clear that across the Kent Surrey and Sussex (KSS) region, the quality of NHS RCA ‘in-house’ training was varied, and when delivered by private providers- very expensive. In addition, the quality, style and content of the investigation reports produced was often inconsistent across the KSS NHS providers of care.

In late 2016 I and my close colleague Mel, were invited to join the Kent Surrey and Sussex Patient Safety Collaborative Serious Incident Communities of Practice (CoP).

From inception, we were both clear that we would be keen to develop a Continuous Professional Development (CPD) accredited training course incorporating a human factors approach to SI investigations and experiential Duty of Candour training.

We also wanted to develop a very collaborative approach, joining NHS providers and commissioners alike to share learning, ideas and concept, and focus together on a more innovative quality improvement methodology.

One caveat, we need to be clear we are not experts in the field, but we openly shared our varied experiences of investigations and
meeting with patients who may have been harmed, or families/carers that are bereaved.

Fast forward from November 2016 to February 2017. (Following many planning meetings, mash-ups and hybrid models being developed at my house with Mel!) and the launch of the pilot course.

Mel and I designed an agenda that fulfilled all the elements of the recommended training, but also incorporated a solid human factors focus (but with a few personal touches of abstract modern art as an aide memoire to our presentations!)

We wanted to design the course so that both days were thoughtfully facilitated, interactive, safe spaces to test, share, and openly discuss practice. Our aim was to spark and generate active conversations with and between the delegates rather than them being the passive recipients of our presentations.  We also wanted to promote confidence within the group to share their own experiences and provide a space in which we all began to work together to develop a solution focus.

We utilised professional actors on day 2 to assist with the scenarios regarding Duty of Candour training. Whilst we both acknowledged this was the most challenging session for the delegates, it also scored the highest scores on the evaluation.

By virtue of sharing our experiences, encouraging and promoting safe and honest discussion, and piloting a proposed standardised training programme, we naturally evolved into a community of reflective thinking and learning… a Community of Practice.

Using a Plan, Do, Study, Act (PDSA) methodology, the positive feedback and evaluation from the pilot course has ensured we can develop and design the course further.

Focusing on the way forward, our main objective is to empower the growing membership of the CoP, actively supporting and encouraging confidence and independence within the group in order for the different members of the community to present and provide an accredited, educational, evolving and progressive training programme.

Jo Habben is Lead Clinician Quality and Compliance, South East Coast Ambulance NHS Foundation Trust, and Melanie Ottewill is Head of Clinical Investigations (National Investigator from March 2017).


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