Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
345 items
1 source
17 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
86match
AFA-4 - Governance
The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get lost due to time pressure. • Develop a comprehensive data and information strategy to support assurance, learning and...
Matched on
terms: governance, patient, safety
Inquiry recommendation
77match
R79 - Board member learning framework
The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient safety). Annual assessments as to the effectiveness of Board performance should be undertaken by PHA.
Matched on
terms: governance, patient, safety
Inquiry recommendation
73match
AFA-2 - Organisational development and cultural reform
The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress....
Matched on
terms: patient, safety
Inquiry recommendation
62match
27 - Disagreement and patient care
Where there is disagreement each party shall reconsider bearing in mind that patient care is of paramount importance. In the event of continued disagreement an arbitrator may be appointed, but in any case the Trust shall take immediate steps to secure proper patient care.
Matched on
terms: patient
Inquiry recommendation
62match
3 - Safety management system content
The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of design should be directed to its review and upgrading so far as that is reasonably practicable (para 21.56)....
Matched on
terms: safety
Inquiry recommendation
62match
2 - Objectives the Safety Case must demonstrate
The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the operation of the installation and its equipment are safe (paras 17.36 and 21.56-57); (ii) that the potential major...
Matched on
terms: safety
Inquiry recommendation
62match
R81 - Expert clinical governance advisory function
The DoH should establish an expert clinical/social governance advisory function to support providers.
Matched on
terms: governance
Inquiry recommendation
62match
R77 - Triennial Board governance reviews
The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Matched on
terms: governance
Inquiry recommendation
62match
R76 - NED with clinical governance expertise
NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should make training in Board-level clinical and social governance available to all NEDs.
Matched on
terms: governance
Inquiry recommendation
62match
R75 - Executive Director of Clinical and Social Care Governance
There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is given to clinical and social care governance. Boards should appoint an Executive Director of Clinical and Social Care...
Matched on
terms: governance
Inquiry recommendation
62match
F62 - Improved patient focus
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Matched on
terms: patient
Inquiry recommendation
61match
F59 - Care Quality Commission independence strategy and culture
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Matched on
terms: patient
Inquiry recommendation
57match
32 - Investigate failing individuals or departments
Where there is good reason to believe that an individual or department may be failing and affecting patient care, it shall be the duty of the Trust with the co-operation of the university, and if appropriate on a joint basis, to investigate. Investigation shall continue until the problems are identified or it is found that in reality no...
Matched on
terms: patient
Inquiry recommendation
57match
29 - Business plan for new ventures
Where a new venture, such as the establishment of a Chair or department, is contemplated, both parties where appropriate shall consider in detail the aims and resources available and draw up a realistic business plan before any final commitment is made. As in all these matters, if patient care is to be included in the venture, patient care...
Matched on
terms: patient
Inquiry recommendation
57match
F67 - Focus on compliance with fundamental standards
The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service delivered to patients, and the sustainability of a service at the required standard.
Matched on
terms: patient
Inquiry recommendation
57match
F60 - Consolidation of regulatory functions
The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Matched on
terms: governance
Inquiry recommendation
53match
39 - Non-medical managers seek medical advice
Hospital managers without medical qualification shall seek medical advice on matters requiring it. If there is doubt as to the need for advice on any matter relating to patient care, the doubt shall be resolved by seeking advice.
Matched on
terms: patient
Inquiry recommendation
53match
28 - Workforce involvement part of the SMS
The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).
Matched on
terms: safety
Inquiry recommendation
53match
F68 - Focus on compliance with fundamental standards
No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied that the organisation currently meets Monitor's criteria for authorisation and that it is delivering a sustainable service which...
Matched on
terms: patient
Inquiry recommendation
53match
F58 - Care Quality Commission independence strategy and culture
Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient perspective directly.
Matched on
terms: patient
Inquiry recommendation
45match
20 - Duty to disclose substantial matters
The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.
Matched on
classifier match
Inquiry recommendation
45match
F61 - Consolidation of regulatory functions
A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area of regulatory activity. It would be vital to retain the corporate memory of both organisations.
Matched on
classifier match
Inquiry recommendation
45match
F54 - Care Quality Commission independence strategy and culture
Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Matched on
classifier match
Inquiry recommendation
45match
F52 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
Matched on
classifier match
Inquiry recommendation
45match
F51 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, including service user representatives, clinicians and any other specialism necessary because of particular concerns. Consideration should be given...
Matched on
classifier match
Inquiry recommendation
45match
F47 - Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Matched on
classifier match
Inquiry recommendation
41match
40 - Independent specialist advice if in doubt
While hospital managers will usually seek medical advice from the medical director or clinical directors in the first instance, if any substantial doubt remains they shall seek advice from independent specialist medical advisers or the Royal Colleges, whether directly or through their regional advisers.
Matched on
classifier match
Inquiry recommendation
41match
34 - Report unresolved problems to regional office
If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.
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classifier match
Inquiry recommendation
41match
33 - Plan to resolve identified problems
Where problems are identified a plan, jointly where necessary, shall be drawn up to resolve them as soon as possible.
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classifier match
Inquiry recommendation
41match
31 - Treat substantial alterations as new
Any substantial alteration in an existing venture shall be treated as if a new venture.
Matched on
classifier match
Inquiry recommendation
41match
16 - Verify container before release
every authorisation for release of organs for burial or cremation must not be completed until the content of the container is confirmed and the form counter-signed;
Matched on
classifier match
Inquiry recommendation
41match
4 - Consider independent incident team
In devising a Serious Incident Procedure the Chief Executive and Trust Board shall consider the need for a serious incident team independent of the hospital.
Matched on
classifier match
Inquiry recommendation
41match
2 - Trust devises incident procedure
In the event of a serious incident the Chief Executive and Trust Board shall devise a suitable Serious Incident Procedure similar to those already in place for major disasters and review it from time to time making any necessary alterations.
Matched on
classifier match
Inquiry recommendation
41match
1 - Develop serious incident procedures
Serious Incident Procedures should be developed and put in place.
Matched on
classifier match
Inquiry recommendation
41match
37 - Permits and isolations remain in force
A permit to work and its consequent isolations, both mechanical and electrical, should remain in force until the work is sufficiently complete for the permit to be signed off and the equipment returned to operation (para 18.8).
Matched on
classifier match
Inquiry recommendation
41match
36 - Mechanical isolation procedure
All permit to work systems should incorporate a mechanical isolation procedure which involves the physical locking off and tagging of isolation valves (para 18.29).
Matched on
classifier match
Inquiry recommendation
41match
34 - Harmonisation of permit to work systems
Standardisation of the permit to work system throughout the industry is neither necessary nor practicable. However, in view of the fact that there is much in common between the systems of different operators, the industry should seek to increase harmonisation, for example in the colours used for different types of permits to work and in the rules as...
Matched on
classifier match
Inquiry recommendation
41match
32 - Permit to work part of the SMS
The operator’s permit to work system should form part of its SMS (para 21.56).
Matched on
classifier match
Inquiry recommendation
41match
6 - Monitoring deaths in hospitals
i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and predetermined route to senior management for the escalation of concerning data trends or patterns.
Matched on
classifier match
Inquiry recommendation
41match
F66 - Improving contribution of stakeholder opinions
The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust for foundation trust status and in particular on whether a potential applicant is delivering a sustainable service compliant...
Matched on
classifier match
Inquiry recommendation
41match
F65 - Quality of care as a pre-condition for foundation trust applications
The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
Matched on
classifier match
Inquiry recommendation
41match
F64 - Authorisation of foundation trusts
The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation of the authorisation process and compliance with foundation trust standards should be transferred to the Care Quality Commission,...
Matched on
classifier match
Inquiry recommendation
41match
F63 - Improved transparency
Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
Matched on
classifier match
Inquiry recommendation
41match
F57 - Care Quality Commission independence strategy and culture
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of the first inquiry, and open that evaluation for public scrutiny.
Matched on
classifier match
Inquiry recommendation
41match
F56 - Care Quality Commission independence strategy and culture
The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Matched on
classifier match
Inquiry recommendation
41match
F55 - Care Quality Commission independence strategy and culture
The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
Matched on
classifier match
Inquiry recommendation
41match
F53 - Care Quality Commission independence strategy and culture
Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
Matched on
classifier match
Inquiry recommendation
41match
F50 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Matched on
classifier match
Inquiry recommendation
41match
F49 - Enhancement of monitoring and the importance of inspection
Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from Local Healthwatch; New or existing peer review schemes; Themed inspections.
Matched on
classifier match
Inquiry recommendation
41match
F48 - Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
Matched on
classifier match