Aim To improve training, learning and quality improvement from root cause analysis (RCA) in wider clinical teams at Guy’s & St. Thomas’ hospital.

Rationale

Although the process of RCAs is robust in the Trust, thematic analysis and sharing learning throughout the organisation could be improved. This was identified in the latest CQC report (2016) which stated that more work was needed to complete investigations into serious incidents in a timely manner and share learning across directorates. Linking quality improvement projects (QIP) to clinical incidents is an important way to improve the quality of our services for patients, carers and staff.

Root Cause Analysis & Serious Incident Fellowship A 6-month fellowship for junior doctors and management staff to gain experience in root cause analysis and take ownership of the QI projects that are recommended as a result.

Duration: 6-12 months

The fellowship will consist of:

• Attending the trust learning from incidents half day
• Attending one of the trusts QI training days
• Attending and being a named investigator on a serious incident investigation
• Attend the relevant SIAP meeting
• Attend two half day feedback and training sessions with the fellowship facilitators

Process RCA and serious incident training

Trainees will attend the trust ‘learning from incidents’ half day organised by GSTT school of improvement. The workshop takes place 3-4 times a year and aims to help clinical staff responsible for leading and participating in adverse event/incident analysis within their clinical services to:

• Understand why it is important to use a systematic approach to analysing an incident or an adverse event
• Use practical techniques to analyse actual events that injured or could have injured a patient and identify the root cause of an event.
• Understand what is needed to properly carry out and act on root cause analysis.

This will also help junior doctor meet their clinical governance requirements as part of their specialty curriculum.

Recruitment to fellowship Trainees will then be offered the opportunity to be part of an investigation team looking into a serious incident. Trainee must be contracted to work in the trust for the next 6 months to be eligible.

RCA and Serious Incident Assurance Panel (SIAP) Each participant will be assigned to an ongoing trust serious incident and will be a named investigator on the RCA report. This will not necessarily be specialty-specific, but every effort will be made to match trainees to relevant RCAs. In addition, participants will be expected to attend the relevant SIAP which takes place each month on a Tuesday morning. Participants will need to swap shifts or apply for study leave to attend.

QI project based on their RCA report/learning Participants will then feedback the recommended QI projects from the RCA report to the speciality leads. Participants may want to be involved and take ownership of the QI project, but this is not mandatory and not required to complete the programme. Participants can be allocated a local QI supervisor/mentor who will work on their project with them and provide guidance where required. Feedback and learning

Participants will attend two half day sessions one to learn QI methodology and secondly feedback their learning and progress. In addition, to obtain their fellowship certificate, participants will need write a short reflective piece on their experience and learning (one side of A4).

To apply, please email: [email protected]