Integrating Risk Management & Moving & Handling

1. Integrating Risk Management & Moving & Handling Richard Hinckley Head of Patient Safety & Risk Management, King’s College London NHSFT Simon Wells Moving & Handling Manager, King’s College London NHSFT

2. Systems for identifying Safety Issues Reactive Proactive Complaints Incidents Claims PALS Inquests Risk registers & Board assurance Framework f Risk Assessments & Observational audit Internal benchmarking (surveys, patient experience) Internal inspection & audit Internal Internal Safety Issues External External Benchmarking (eg. via inpatient surveys) Trends from national reporting (NRLS) External inspections/ assessments (NHSLA, CQC, HSE) Performance targets Safety notices (MHRA, Rule 43 etc) National guidelines (NICE), NCEPOD reports etc. Reactive Proactive

3. Identifying & Managing Safety for M&H Focus on 2 specific systems: • Reporting & managing incidents allows processes to be changed to stop incidents recurring & prevent potential harm turning into actual harm • Observational audit permits assessment of actual practice & real-time feedback. Training & equipment deficits can be identified & addressed immediately

4. Identifying & Managing Safety for M&H 1. Incident management • Reporting systems • Investigations • Ensuring improvement 2. Observational audit • Format of audit • Integration of improvement into local practice

5. Incident Management An effective incident management system will: • Identify a wide range of risk issues in sufficient detail in a timely way • Triage risk issues according to seriousness (prioritisation & proportionality) • Investigate incidents in a structured way (RCA) • Engage local teams to ensure learning is embedded into practice • Feed into local governance systems to ensure learning is sustained

6. Incident Management: Reporting • Online reporting form (with drop-downs): • Easy to complete • Provides instant reference number • Allows emails to be auto-generated (eg. to M&H team) • Web-based system • Access to system flexible – allowing designated staff to see incidents details, investigation progress & action plans • As M&H team alerted to all AIs with type = M&H, can respond immediately

7. Incident Management – Reporting • A successful reporting system should consider: • Identification of risk leads within clinical departments (need clinical buy-in from outset) • Staff training (need training programme & resource to deliver it) • Form design (must be user friendly – user testing) • Responsiveness to departmental needs (this should be tempered by need for minimum data) • Feedback to staff (if not possible via system, then via cascade from risk meetings, newsletters etc) • Corporate focus (duty of all staff to report AIs)

8. Incident management – investigation • All incidents “approved” by Risk Manager or delegated risk lead in clinical area. Involves assessment of seriousness • Level of investigation determined by seriousness • Incidents with moderate harm = investigation report • Incidents with major harm/death = full investigation • Use of Root Cause Analysis (RCA) helps identify structural (rather than personal) causes

9. Incident Management – Investigation Indicate whether the event directly led to harm, did not directly lead to harm, or whether the event was prevented from occurring. If harm was caused, then an additional field will appear asking for the degree of harm. The help icon will provide guidance on what each option means .

10. Incident Management - Investigation Effective incident investigation involves: • Structured approach to investigations • standard investigation templates • use of specific RCA tools (5 whys, After Action Review, timeline, wishbone etc) • clear deadlines & reporting structure • Pool of trained local clinicians that can be tapped into (M&H link worker programme; investigations training programme) • Quality of investigation (& findings) reviewed at local and Trust risk meetings (M&H input)

11. Incident Management – Improvement Sustained improvement via investigation involves: • Local ownership of action plans (clearly identified local leads with deadlines) • System for monitoring • Tracking of actions via local committees • Periodic review of implementation (link to NHSLA) • Scorecards • Link to Trust audit programme • Shared learning(newsletters & reports, events to raise awareness)

12. Example: M&H Incident (1) • Sedated neuro patient fell to floor during transfer between operating table & bed post-surgery • No incident form completed (M&H team informed later by theatre link worker) • MH investigation revealed bed brakes not applied & no patslide used during transfer, surfaces parted & patient fell • Outcome: bespoke training for local area - reinforcement that equipment must be checked & patslides used & AI completed. Without link worker investigation wouldn’t have occurred

13. Example: M&H Incident (2) • AI - Back injury due to carrying heavy back pack during transfer of patient from ward to x-ray • M&H advisor assigned investigation which identifies as nurse (with backpack) walked through lift entrance, doors closed trapping the back pack and pulling the nurse backwards. Back injury resulting in time off work & light duties when she returned • Incident due to lift door pressure sensors not working properly & open doors automatically

14. Example: M&H Incident (2) Investigation findings & actions: • Pressure release locks on certain lifts not working - problem known to Estates but never reported to other staff groups (so not acted upon) • Lift mechanism investigated and repaired by Estates post-incident • Service managers now aware of issue & workers informed • Review carried out of how back packs can be carried or supported on bed during transfers

15. Example: M&H incidents (3) • Issue: clinical staff experiencing back pain (esp. theatres). Identified via AIs & feedback at training • M&H Investigation • Risk factors (frequency, route, cumulative strain, poor work practices by porters) Outcome: • Change in training for porters • Purchase of 4 powered bed movers for porters • Reinforce at MH training how to move beds

16. M&H Observational Assessment Back ground • Wanted to supplement yearly audit of MH equipment in clinical areas • Some way of collecting ‘live info’ on what workers really doing in practice when MH patients • Simple, easy to complete system • Easy format to feedback to respective divisions at Risk & Governance meetings

17. Information collected • M&H incidents (AIs) reported in area, & of these no. resulting in WRMSD • No. of workers on Long Term Sickness absence due to WRMSD • M&H equipment available against M&H Equipment Standard • % workers with in date M&H training • Assessment of Moving & Handling activities in the workplace • Patient handling activities • Load handling activities

18. Assessment of MH activities in the workplace

19. Findings from Neuroimaging Assessment Findings & actions: • Equipment available (eg. for lateral t/f) but not used correctly (attendance at dept. to identify better use of equip) • Consultants had not attended MH training (focussed M&H training session arranged) • Equipment required to take testing equipment into domestic environment (folding trolley identified & procured) • No M&H link worker (worker identified & training booked)

20. Summary • Years programme of M&H Obs. Assessments in clinical areas • ‘Live’ information & timely delivery to the coalface • Additional information for use in training room • Feedback on impact of training in the workplace • Additional information on level of compliance with Trust MH Equipment Standard (2009) • Link to incident trends