Essential Questions for Governors about Patient Safety and the Importance of Being Open

1. Essential Questions for Governors about Patient Safety and the Importance of Being Open Kate Beaumont Head of NHS and Patient Engagement Emma Forbes Patient Engagement Lead National Patient Safety Agency Catherine.beaumont@npsa.nhs.uk and Emma.forbes@npsa.nhs.uk

2. What is patient safety? • Patient safety is defined as the avoidance and prevention of patient safety incidents resulting from the processes of health care delivery. • A patient safety incident is defined as any unintended or unexpected event that could have or did lead to harm for one or more patients receiving NHS funded care.

3. Does everyone understand the importance of patient safety? Why is it important? A clear and explicit view of patient safety is the foundation for setting goals and standards. Patient Safety is everyone’s responsibility and everyone needs to understand what it means for them.

4. You might want to ask; • What are your specific goals for improving patient safety? • Has the board made a public commitment to ensuring patient safety is a top priority? • How do you measure the achievement of these goals at the end of each year?

5. Does our trust really have an open and fair culture? Why is it important? • Staff are less likely to report errors or raise safety concerns if they are punished or blamed. • Most errors are as a consequence of weaknesses in the system which then affects the performance of the individuals within that system. • A culture of blame can drive reporting underground and prevent us from learning what makes things safer.

6. You might want to ask; • What commitment has been made by the Board to an ‘open and fair culture’? Can we see evidence of a public commitment to this?  Do managers use the NPSA’s Incident Decision Tree when something has gone wrong? • How many errors and incidents that have affected patient safety were reported by staff last year? How does this compare to numbers reported by similar organisations? • Can you provide stories showing what happened in a sample of these reports and the outcomes for the organisation?

7. Does the trust actively encouraging reporting of incidents? Why is it important? • Organisations that report more incidents usually have a better and more effective safety culture. • We can’t learn and improve if we don’t know what the problems are. • It is important to know what happened and why it happened.

8. You might want to ask; • What steps have been taken to encourage front line staff to actively report errors and incidents that affected patient safety? • How do you measure the success of this process?

9. Does the trust, and do we, get the right information? Why is it important? Learning from all sources of data together provides an organisation with a true reflection of where things are going wrong and what is needed to prevent minor incidents from becoming serious incidents.

10. You might want to ask; • What is the Hospital Standardised Mortality Ratio for the trust (HSMR)? • How do we know that there are sufficient nursing staff on duty at all times? How is this monitored and is there a tool used to calculate this? • How do we know our discharge planning works well?  • What are our systems to reduce avoidable harm and death in recognised high-risk areas, for example, Venous Thrombosis (VTE), wound infections etc?

11. Are we always open when things go wrong? Why is it important? • Communicating effectively with patients and their carers is a crucial part of dealing with errors or problems in treatment. • Saying sorry, providing an explanation and keeping them informed will help patients and their families to cope when things have gone wrong. • It is also vital to provide staff with support to cope with the incident and to help them communicate well.

12. You might want to ask; • How many staff have had training in Being Open?  • How do you monitor Being open? • How do you evaluate it? Have there been any audits to find out if Being open principles are being followed throughout the trust?

13. Does the trust learn from patient safety incidents? Why is it important? • The response system is always more important than the reporting system. • A robust methodology should be in place to ensure incidents are thoroughly investigated and any recommendations are implemented successfully. • Providing feedback will enhance reporting and learning. There must be clear, rapid, and useful feedback on lessons learned and actions taken.

14. You might want to ask; • How does the organisation engage with representative groups and respond to concerns raised? • What issues are raised from patient feedback/PALS/Staff survey that highlight possible patient safety concerns? How are these issues acted upon?  What changes have been made to improve patient safety as a direct result of receiving this feedback? • What process is used to ensure that recommendations are fully implemented in the long term?

15. Does the trust actively implement national guidance and safety alerts? Why it’s important? • It is vital to learn lessons from outside the organisation as well as from local information.

16. You might want to ask; • Can you provide evidence for the implementation of all relevant national guidance on patient safety and safety alerts? • How do you ensure that actions for patients’ safety guidance and safety alerts are embedded in the work of the organisation for all staff? Go tohttp://www.nrls.npsa.nhs.uk/home/ for references, tools and further guidance.

17. Being open……..is a philosophy; a set of principles that healthcare staff can use to communicate with patients and their carers, and with each other.

18. What is Being open? Being open supports a culture of openness, honesty and transparency. When there is a patient safety incident it is about acknowledging when something has gone wrong, saying sorry, and explaining what happened and what will happen next.

19. Ten key principles 1 Principle of acknowledgement 2 Principle of truthfulness, timeliness and clarity of communication 3 Principle of apology 4 Principle of recognising patient and carer expectations 5 Principle of professional support 6 Principle of risk management and systems improvement 7 Principle of multidisciplinary responsibility 8 Principle of clinical governance 9 Principle of confidentiality 10 Principle of continuity of care

20. Being open review – actions for trusts • Ensure that organisations have in place a local policy, based on the NPSA’s updated Being open alert • Identify, and provide training to a minimum of threeBeing open Expertsor Champions • Nominate Executive and Non-Executive leads responsible for ensuring that the Being open principles and policy are embedded in the organisation. • Make a public commitment by the Board, to Being open, honest and fair in all that the organisation says and does. • Raise awareness of the Being open principles and local policy • Ensure PALS and Complaints staff have the skills and processes in place tosupport patients through the Being open process

21. How can Governors get involved? Raise Being open at Governors’ meetings • How many staff have had training in Being open?  • How do you monitor Being open • How do you evaluate it? • Have there been any audits to find out if Being open principles are being followed throughout the trust?

22. And champion Being open principles in your trust!