case 1      case 2      case 3      case 4      case 5      case 6      case 7      case 8      (1) THE POLISH MOTHERS' MEMORIAL HOSPITAL FOR WOMEN AND CHILDREN Rzgowska 281/289, 93-338 Lódz, PolandandCENTRAL AMBULANCE SERVICE IN LÓDZWarecka 2, 91-202 Lódz, Poland ORGANISATION ACTIVITIES An example of the neonatal transport in LódzNeonatal transport has always been a difficult task, especially in areas with high rate of praematurity and lack of specialized equipment. In 1995 three medical institutions: The Polish Mothers' Memorial Hospital for Women and Children, The Paediatric University Hospital in Lódz, and Central Ambulance Service in Lódz begun a joint initiative - a 24 hour a day, specialized, highly organized transport service for sick and immature babies. The ambulance is equipped with an intensive care incubator, mechanical ventilator, monitor of vital functions, infusion pumps, air compressor, oxygen cylinders etc. The staff includes 4 people - a physician, a nurse, a paramedic and an ambulance driver. STRATEGIES A. THE POLICY This program included assessment of related risks for the medical staff and for the patients. Because of the special risks involved, the medical personnel as well as the equipment received a special insurance by the State Insurance Company. Safety regulations for the transport were developed and written down. B. THE PROCESS In 1996 the ambulance was involved in an accident in which the nurse was seriously injured, and physician on duty was slightly injured, and the car with most of the equipment was destroyed. Following this crash an urgent meeting of all personnel was held and after a discussion new safety regulations proposed and implemented. TRAINING The new regulations restrict the use of fast journey with the so called ´'siren'´ signal during transport, only to extreme situations when the patient's life is in immediate danger. All such cases must be reported. Special attention was paid to fastening of seat belts and restraining of all devices used on transport: the incubator, monitor, infusion pumps etc. The teaching of all the staff of first aid, and how to deal with a serious traffic accident was performed. IMPACT AND PERCEIVED BENEFITS The risk of another accident was reduced, and during the next 9 years such problem did not occur. Implementation of safety regulations has been recognized as successful. ACTION POINTS FOR THE FUTURE The Transport Service intends to: Secure funding for a new ambulance with medical equipment (the old ambulance has already covered a distance over 600.000 km - sixty thousand km) Increase medico-legal awareness by identifying areas of concern and organizing seminars Back to Top (2) PAEDIATRIC UNIVERSITY HOSPITAL IN LÓDZ Sporna 36/50, 91-738 Lódz, Poland ORGANISATION ACTIVITIES The Paediatric University Hospital employs 250 personnel and has 270 beds for patients. In 1996 new Government Regulations were implemented in the area of Risk Management. One of these regulation is devoted to training of all the staff in the field of safety precautions at work. Since 1996 all newly admitted personnel undergoes such a training and receives a special diploma. All performed lessons and courses are registered. After the first training there are renewal courses performed on a regular basis. STRATEGIES A. THE POLICY According to the "Safety at Work" regulations from 1996 the training about safety, and risk at work is done :· Shortly after the new person is admitted, or after change of post (primary training) - not later that 6 months after the beginning of work;· Regular (renewal) training - For auxiliary and technical staff - once every three years;- For medium level medical staff (nurses, laboratory personnel) - once every 3 years; For upper level medical personnel (physicians) - once every six years. B. THE PROCESS The General Manager of the Hospital has organized a special Team for the Assessment of Risk at Work The aim of this team is to assess the risk for personnel at all different working posts including the medical and non-medical ones. They used data from previous risk assessments, the registry of accidents at work, data about measurable factors (radiation, noise, medical gases and vapors) and information from individual departments. The Risk Score was implemented to analyze all individual posts and to outline prevention strategies TRAINING The assessment of the program was carried out by the Lódz office of the "State Inspectorate of Work" and the system used in the Paediatric University Hospital was recognized as being in compliance with the Government Safety and Hygiene At Work Act from 1996. IMPACT AND PERCEIVED BENEFITS The risk of accidents at work was reduced, and their incidence has dropped sharply. ACTION POINTS FOR THE FUTURE The General Manager of the Hospital intends to perform regular medical tests among all personnel. Back to Top (3) POLYPROFILE HOSPITAL, BURGAS ORGANISATION ACTIVITIES Polyprofile Hospital for Active Treatment (PHAT) Burgas is the main hospital in the area. Two years ago an Epidemiological link was formed and procedures for reporting cases of Inner Hospital Infections (IHI) were initiated for helping their limitation and prevention. STRATEGIES A. AIM Making a study of the dissemination and dynamics of the Inner Hospital Infections in the different wards of the hospital and as a whole. Making a study of the causes and factors for IHI, conditions for their arising, running, duration and consequences. Mapping out practical measures for their prevention. B. THE PROCESS Forming a Commission of IHI that includes:     o Chairman from the hospital management     o Epidemiologist     o The chief doctors of the wards Establishing Epidemiological link of epidemiologist and an assistant epidemiologist, that works in direct contact with the chief doctors of the wards, the microbiological laboratory and the Medical Director of the Hospital. Methods that were used:     o Analytic epidemiological researches in the risky wards and in the hospital as a whole for proving the casual connection between the different social factors and concrete cases.     o Making possibilities of prophylaxis by interventions, directed to reducing and complete removal of the respected factors.     o The data for the researches have been collected on the basis of weekly check-ups by the assistant epidemiologist and monthly verifications by the epidemiologist of the hospital in the risky wards and in the hospital as a whole.     o The data have been generalized by the epidemiologist in co-operation with the statistical section of the hospital.     o Giving the data, generalized by the epidemiologist, to an IHI commission monthly, as well as at three and six-month period, and every six months to the Anti-epidemic Control Ward of the Hygiene-Epidemiological Inspection- Burgas. Carrying out a purposeful screening among the highly risky groups in definite wards and fixing the specifically exposition of risk of IHI. Carrying out a large-scale screening in all hospital wards and valuing the prophylactic program. Improving the sanitary-living standards and the technical equipment in the hospital.· Redirecting financial resources from medicinal to prophylactic activities. TRAINING Raising the qualification of the epidemiologist and the assistant epidemiologist by participation in seminars and programs, implemented by the Ministry of Health. Exchanging experience and knowledge with the respective hospital epidemiologists in the country. Carrying out lectures and seminars by the epidemiologist for educating the middle and high medical personnel on the questions of IHI in the hospital. IMPACT AND PERCEIVED BENEFITS QUALITY OF THE STRUCTURE: The building fund is being maintained and repaired appropriate to the new raised sanitary-hygiene requirements. Renovating and complementing the technical equipment, including this in the laboratory of the hospital. An epidemiological link is set up. It functions and increases the effectiveness of its work. The procedures of connecting the link with the wards in the hospital and leading a struggle with IHI are set up and confirmed. A commission for struggling with IHI has been founded. QUALITY OF THE PROCESS: The quality of the process has been defined by evaluation of the prophylaxis program. Assessment of the realization - point of fulfilment of the planned prophylaxis activities and enveloping of the target population (they are compared the completed to the advanced planned activities) Assessment of the effects - if the program has reached the preliminary aim - decreasing the number of IHI and risky factors. Assessment of the prophylaxis process - long-term surveillance and analysis the level of risky factors as the time passes. Assessments of the outlays - if the outlays of a particular prophylaxis program correspond to the reached results. For the last two years, as the link started working, its effectiveness and impact has been proved by empirically determined decrease of IHI and the risky factors of its advent. The outlays of the hospital in connection with IHI treatment has decreased, as well as the patients' dissatisfaction caused by its advent and the average patients' stay in the hospital has been cut down. ACTION POINTS FOR THE FUTURE The policy of struggle against IHI is about to develop and improve, because of its proved positive effect.It's expected that the patient should be also involved to take sides of pursuing the policy and restricting the risks for IHI. This will contribute to the increasing of his information about risks of IHI and consciously observing the rules for preventing IHI. In about three years the hospital will have a considerable informational massif about the risky factors, which cause IHI. This will allow improving the active rules and work procedures for avoiding and preventing IHI. When taking a job, the personnel are given initial instructions for safety and labour protection. In the years to come in these instructions will be added the prescriptions for struggling with IHI and they will be carried out annually. Back to Top (4) GROUP PRACTICE FOR PRIMARY HEALTHCARE "MEDIAS" ORGANISATION ACTIVITIES In the group practice of primary healthcare "Medias" work 2 doctors and 2 nurses. The practice serves more than 3800 health insured, according to concluded contract with the Regional Health Insurance Fund (RHIF) - Sofia City. The Practice began its activity in July 2000, parallel with the change in the outer-hospital care. STRATEGIES A. THE TERMS The new system for primary healthcare introduced on 01 July 2000 faced us the challenge to work with many more new and unfamiliar patients. The need to orient in their health status was the most responsible challenge before us. The change in the structure of the primary healthcare, in the ownership and the introduction of market relations confront us in front of non-typical and unknown activities. In these rousing conditions we managed to build gradually our practice, communication between our colleagues and us, relationship with our patients, to earn their trust. This is a strategy which turned out to be successful in the last 3 years and which we will continue to realize in future. B. THE PROCESS Our first step was to find a suitable premises and medical equipment to function the practice and meet the requirements of the RHIF for concluding a contract. The process started with the signing of the first contract with (RHIF) - Sofia City. It regulates our attitude and the paymaster from the RHIF for the service, given to health insured people To manage with the problem " too many unknown people" we started building a file with medical records of every one of them:     o The first examination of the patient is very detailed - we inform ourselves about family inconvenience, former illnesses, risk factors about his way of life. We also make a very detailed medical examination.     o We write the data of the first examination in the medical file and the results we mark by a definite way (with the help of coloured stickers), in order to ensure a quick finding of the information about health status and common pathology at every of the following visits of the patient.     o In this way even the leading doctor is away, his colleague will be able to orient himself very fast where to look for the patient's record, which are the major illnesses and to find the chronology of the illnesses.     o We renovate the information in the files with every subsequent examination of the patient o we already have a full file and medical record of all our patients, which makes our work easier.     o We collect a huge amount of information for all of the examinations and consultations. The ones that are not actual any more, we put in archived file, as we mark on the active record that the information is stored there. As we base ourselves on the information in the records, we inform our patients when to come for a prophylactic examination. In this way we not only care for their health status but the prophylactic activities help to improve the relations with the patients. To respond to the challenges of the market rivalry, we made operations in order to increase the qualification of the medical personnel. One of the doctors has two specialties and the other is going to have the specialty "General Medicine". The practice is going to be authorized as a "pilot practice" where courses are going to be hold for doctors in order to acquire the specialty "General Medicine". We made active connections with specialized health enterprises and hospitals, in order to ensure our patients with comfort and qualified attention of a specialist.. We strictly obey the instructions of NHIF/RHIF and work according to the national and regional priorities and programs. TRAINING One of the doctors has graduated a specialty under the program of "General Medicine" in the Medical University of Sofia. The other has acquired specialties in "Inner Illnesses" and "Cardiology". Legal documents - the necessary requirement of work is to know well the legal framework, including the requirements of NHIF/RHIF. Thus the personnel annually make itself familiar with the newly signed national framework contract with the NHIF and the individual contract with the RHIF. IMPACT AND PERCEIVED BENEFITS The patients are pleased with the quality of our work, the attention we pay for them and the result that they receive. We are pleased with the achievements and with the professional realization, we obtain. The number of the patients who want to include in the practice is rising, but for now the capacity we have does not allow us to include new health insured, without reducing the quality of the service. We have a detailed file of our patients, which makes our work easier. ACTION POINTS FOR THE FUTURE We have 2 computers, which are going to be used for working the information and for making reports for the RHIF. Thus we expect to make our work easier. We expect to include one more doctor in the team, in order to improve the capacity of the practice. In this way we will be able to ensure more patients however we keep the quality of the service. We always must keep the qualification in the highest possible level. The profession of a doctor demands continuous process of qualification and renovating of the knowledge and we aspire to be good professionals. Back to Top (5) ST. VINCENT'S UNIVERSITY HOSPITAL, DUBLIN ORGANISATION ACTIVITIES St Vincent's University Hospital, Dublin is a major academic teaching hospital, affiliated to University College Dublin, committed to patient focused care. St Vincent's University Hospital is a member of the Irish National Health Promoting Hospitals network. The hospital employs over 2000 personnel. It has a dedicated risk management committee and participates in the risk management forum which comprises academic teaching hospitals within Dublin and other hospitals within the eastern region, focussing on areas of mutual interest in terms of clinical risk management. The hospital's mission statement states "We strive for excellence in meeting the holistic needs of our patients in a caring and healing environment in which the essential contribution of each member of staff is valued." STRATEGIES A. THE POLICY The risk policy at St. Vincent's Healthcare group is focussed primarily on patient safety and staff safety. The fundamental bedrock on which it is based is 'Do no harm'. There is a top down and a bottom up approach to this policy. It is everybody's business and not vested in one individual, be it either a clinical risk manager or an insurance claims co-ordinator. The philosophy and methodology has been adapted to help create and maintain this norm. The hospital reinforces good practice in terms of education, a non-punitive environment, and appropriate accountability. Clarity of understanding leads to accuracy of response in relation to this risk management policy and process. B. THE PROCESS To ensure effective outcomes of risk management St Vincent's University Hospital uses: Data analysis to develop useful information in terms of trends of incidents and adverse events; feedback from clinicians and other relevant staff in relation to what works and why, what doesn't work and why in the area of clinical risk management practice in the hospitals Participation in the risk management forum which comprises academic teaching hospitals within Dublin and other hospitals within the eastern region, focussing on areas of mutual interest in terms of clinical risk management Induction of staff groupings including medics, nursing, allied health professionals, technicians and technologists in terms of entry of these people into the system of St. Vincent's Healthcare Group so that they know that the importance of clinical risk management is a mainstream activity rather than extra curricular Including in staff's job descriptions the importance of clinical risk management so it is seen as part of their job description and job role at all stages of their employment Fundamentally, making risk management a mainstream activity, rather than an activity which is seen as one that can be taken on board if people choose to. We deem that it's so fundamentally important that it has to be woven into the fabric of peoples' daily work in clinical and clinical support areas of activity. The hospital engages in the following good practice risk management and medico-legal activities: Risk management, health and safety and Occupational Health programmes for the three hospitals within the group Accreditation and other quality improvement frameworks to give clinical risk management a context within overall quality activities Provision of lectures, briefings, education meetings, from medico-legal experts, risk management consultants, and the use of debriefings after near misses or incidents to help inform people better as to what happened and why it happened Access and use of expertise in terms of individuals from outside Ireland, Insurance brokers and Risk Managers and partnership with the hospital's insurers so that it's not just about transferring risk, it's about managing and dealing with it because it is inherent in the delivery of healthcare The development of core competencies within the healthcare groups such as root cause analysis and the development of clinical audit The use of clinicians in the area of clinical risk facilitation. The hospital has developed an initiative where one of the anaesthetists at consultant level provides clinical risk facilitation to the ethics and medical research committee and also acts as an advisor to the medical board and medical executive on clinical risk management issues. IMPACT AND PERCEIVED BENEFITS The hospital has experienced a number of benefits: The creation of a more open culture Shared responsibility for management of clinical risk The embedding of actions to improve risk management and quality outcomes within departments and at service level Collaboration between multidisciplinary groups in addressing the inherent risk of healthcare provision in an acute setting The promotion of research into relevant areas of clinical risk such as medication errors, manual handling and back care, needle stick injuries, infection control issues, dealing with toxic substances Addressing the whole psycho-social issues which are coming to the fore, such as bereavement and loss for healthcare workers who are faced with death and very sad circumstances of patients on an ongoing basis. ACTION POINTS FOR THE FUTURE To ensure that the policy succeeds, the hospital intends to: Increase medico-legal awareness by examining key areas of concern and providing lectures, briefings and education meetings from medico-legal experts and risk management consultants Organise further major risk management events to ensure that a culture of safety becomes the norm in the hospital Aim to have recognised accreditation in place within 2 years Improve communication with patients and patient advocacy groups in a preventative way rather than solely after adverse events have occurred Promote an environment where all staff, non-clinical and clinical at consultant or non-consultant level are involved in and aware of the risk management process in the hospital Ensure clear, written policies and training in identified problem areas such as DO NOT RESUSCITATE orders, record keeping and confidentiality Back to Top (6) AMNCH, TALLAGHT HOSPITAL ORGANISATION ACTIVITIES The Adelaide & Meath Hospital Dublin, incorporating The National Children's Hospital (AMNCH), Tallaght employs over 2500 personnel and is among the largest hospitals in Ireland. It has a dedicated risk manager who reports to the CEO and is responsible for coordinating planning and developing strategies to overcome risks and minimise incidents that occur in the hospital. The hospital has recently undergone accreditation and is awaiting the report. The hospital's mission statement includes providing the highest quality health care to all patients and educating all staff and students to the highest international standards. STRATEGIES A. THE POLICY This hospital established a Risk Management Strategy in 2000 The Strategy is based on four key elements: An Education Programme; An integrated Good Practice Team; Communication; Claims Management The underlying ethos of the risk management strategy is concerned with good and safe practice. B. THE PROCESS The Risk management process involves the implementation of the four key elements above: The Education part of the strategy is the main focus, involving regular workshops to dispel myths about what risk management is about, and to encourage the important cultural change that's required within healthcare to promote incident reporting. The education programme is aimed to incorporate analysis into people's everyday practice so that every single person in the organisation is a risk manager. The Integrated Good Practice Team is equivalent to a risk management committee. The group is called the integrated good practice team because of the need for hospital staff to work together. It is considered that there is a healthy synergy amongst staff in the hospital, whereby a group can come together in a committee and work together to try to problem solve. Communication is probably the most important aspect of the strategy, and it's an area that has been recognised as requiring improvement. By the end of 2003, it is hoped there will be a national incident reporting database, from which the data will be fed back to department heads so that they can use it to continually improve their practices. The data will also be important in communicating with financial decision makers within the hospital. Risk management provides good hard data, it's a universal language, a language that can speak to non-clinicians, to clinicians, to management and to all involved in addressing the deficits within healthcare. Claims management within the hospital is being developed in order to make the process as efficient and effective as possible. In addition: The hospital has established a dedicated risk management division Clinical staff receive a medico-legal/risk management training manual The hospital is currently recruiting ICT personnel to develop websites, news sheets, and alert bulletins - all of the things that will improve communication within the departments. The hospital promotes the integration of risk management into the everyday activities within the hospital, and want to introduce a culture whereby everybody is responsible for risk management A group of staff, including the Chief Executive Officer has undergone incident investigation and root cause analysis training The hospital has developed an effective internal claims review process Management and clinicians are brought together to solve problems benefiting from each participant's particular expertise IMPACT AND PERCEIVED BENEFITS An increased awareness of risk management and safety issues - The hospital has seen a threefold increase in incident reporting since education sessions began in the hospital The introduction of a 'safe' forum for staff to raise issues, without feeling a sense of betrayal or a fear of reprimand There has been an improvement in staff morale since the introduction of the risk management process It is envisioned that the improvement of the risk management process will, over time, directly reduce costs relating to litigation Although it is difficult to say if patient complaints have reduced in number, risk management has certainly had an impact on patient care in the hospital. ACTION POINTS FOR THE FUTURE To ensure that the policy succeeds, the hospital intends to: Develop the role of risk management within the hospital in order to integrate it into everyday practice The hospital have a Forum for Adverse Incident Review, where a team of senior management, risk management and clinicians meet to discuss the lessons to be learnt from adverse incidents, complaints and claims experience. Develop new and effective means of education and training for clinical staff in the area of risk management without having to withdraw them from their everyday activities Use accumulated risk management data to influence funding decision-making in order to adequately address the deficits within healthcare In conjunction with experts in the area, develop the hospital website to include a dedicated section on risk management Improve communication within the hospital with the aid of the website, news sheets and alert bulletins Continue the involvement of senior staff, including the CEO, in the risk management process in order to emphasise the importance and necessity for risk management Continue to encourage a change in culture within the hospital so that staff feel secure and safe in raising issues which might otherwise be swept under the carpet Back to Top (7) Burnley Health Care NHS Trust Stimulus to Develop Good Practice Risk Management Strategy: Preparation for compliance with Standards introduced under the Clinical Negligence Scheme for Trusts (CNST), administered by Willis Ltd on behalf of the National Health Service Litigation Authority (NHSLA). The development of the strategy was also driven by a desire to improve patient care and to reduce litigation costs. STRATEGIES A. Steps in the implementation of the Strategy Clinical Risk Manager, CRM, post since 1998 Clear Trust Board support      a) Medical Director given lead for clinical risk      b) CRM has direct access to him and also Director of Nursing & Quality      c) CRM has open access to Chief Executive Clinical Risk Management Group, CRMG, established as sub group of the Risk Management Steering Committee CRMG responsible for formulating the clinical risk management strategy and all clinical risk policies. Increased levels of reporting of incidents; the percentage of medical staff reporting clinical incidents has risen by 17% in last quarter. Trust-wide Clinical Risk Assessment in every ward & department by clinical risk team. The results were presented to the Trust Board. An open culture rather than a blame culture. Root cause analysis is a powerful tool to encourage this approach (see below). A number of clinical risk-related groups have been established that involve support of the clinical effectiveness manager (see below) Both the clinical risk manager and the claims manager were funded by the Trust to undertake a post graduate course in claims handling and clinical risk management at the University of York. The services of a risk management consultant were brought in to review the clinical risk management systems in place. Clinical risk management is included in all inductions and the clinical risk team meet all junior doctors when they start. Consultants attend individual sessions as part of their induction. Consent training was held to introduce the Consent Policy using the Medical Protection Society training resource and special workshops have been held for particular groups. (further information below) B. The Culture Panels review events in serious clinical incidents, SCI, prompted by the ALARM Protocol for Investigation of SCI. Anonymised recommendations are published through the clinical governance route and action plans are monitored for implementation. C. Alignment with other Initiatives: Groups established include: Medication Errors Working Group, Medical Records Working Group, Caldicott Committee, Transfusion Group, Infection Control Group, PALS Clinical Risk Group, Theatres Clinical Risk Group, Rehabilitation Risk Group. TRAINING Shadowing of the clinical risk manager provides an excellent staff development opportunity. Sessions on incident reporting, consent, documentation, complaints handling, inquests and the human rights act are held regularly for junior doctors and other grades of staff. Outcomes of the Strategy: Many are outlines above. In March 2002 the Trust achieved full compliance with Level 2 of the Standards of the CNST scheme. Back to Top (8) London Ambulance Service NHS Trust Stimulus to Develop Good Practice Risk Management Strategy: Preparation for compliance with Standards introduced under the Clinical Negligence Scheme for Trusts (CNST), administered by Willis Ltd on behalf of the National Health Service Litigation Authority. The development of the strategy was also driven by a desire to improve patient care and to reduce litigation costs. STRATEGIES A. Basis of the Success of the Strategy: Comments of the CNST Assessor: Success has been achieved as a result of: A strong awareness of clinical risk issues is part of the culture of this Trust Awareness has percolated through to staff at all levels A well-structured implementation team, involving Senior Management and Team Leaders. Excellent documentation control Trust-wide risk assessment approach Excellent records-keeping audits and development of clinical audit indicators. Prominence of risk issues in the Staff Newsletter. A well thought out Improvement Programme, demonstrating a commitment to staff, patients and the organisation. Outcomes of the Strategy: The Trust believes that the multi-disciplinary approach adopted for risk assessment initiatives was especially useful in increasing the level of understanding and application of risk management policy throughout the Trust. The Trust's risk register has resulted in better clinical surveillance and encouraged the reporting of new risks. The Staff Newsletter has been used to communicate the lessons learned from complaints, enquiries and claims and to encourage the reporting of untoward incidents and near misses. Examples of changes in practice which have been introduced through the risk management process include:     o Upgrading the priority of 999 calls about meningococcal disease and anaphylaxis     o Advice about not extending the time on scene to await the arrival of a midwife. The introduction of first line clinical supervision with team leaders has resulted in improved patient care, documentation, and patient care audits. The identification of life threatened patients, in particular those with acute coronary syndrome, has resulted in developing closer working with the A & E departments across London. The introduction of the Lifepac 12 monitor/defibrillator, with the capacity to produce a diagnostic 12 lead ECG has facilitated the reduction in A & E departments' "door to needle" times. CNST Assessment: Having achieved full compliance at Level 1 of the CNST Standards, the Trust was successful in maintaining full compliance with the Level 2 CNST standards in May 2002. Back to Top