RT Journal Article
SR Electronic
T1 108 The establishment of a risk and safety committee in a private healthcare organisation
JF BMJ Leader
JO BMJ Leader
FD BMJ Publishing Group Ltd
SP A41
OP A41
DO 10.1136/leader-2020-FMLM.108
VO 4
IS Suppl 1
A1 Kechagioglou, Penny
A1 Chaldecott, Robert
YR 2020
UL http://bmjleader.bmj.com/content/4/Suppl_1/A41.1.abstract
AB Background A culture of patient safety in Healthcare ensures that patients are treated right every time. To develop and sustain a patient safety culture requires a whole system approach and the role of clinical leaders is key.Methods Our organisation’s Leadership team audited all incidents weekly between September 2018 and January 2019 and found variable incident reporting rates amongst our clinical facilities. Lessons learned from incidents were not well cascaded to front-line teams. A Just Culture framework tool was piloted between January and August 2019 in an effort to improve incident reporting rates. This led to the establishment of a weekly multidisciplinary Risk and Safety Committee in October 2019, led by a Regional Physicist with expertise in Quality and Safety and the Medical Director. The RSC members represented front line teams, middle managers and the UK Leadership team. The weekly RSC facilitated risk analysis and the timely and accurate completion of Root Cause Analyses (RCA) by implementing a Just Culture policy.Results The clinically led Risk and Safety Committee was established as a multidisciplinary forum where people felt safe to discuss healthcare incidents. The SBAR (Situation, Background, Analysis, Recommendation) reporting tool and the 5 Why/A3 process RCA tool were used to support a deep dive into root causes. An RCA registry with actions and lessons learned was established which facilitated the cascade of information to all teams. After six months of being operational, there have been 300 quality improvement actions documented by the RSC, 90% of which have been effected successfully.Conclusions The successful implementation of the Risk and Safety Committee in our organization was the result of clinical and non-clinical leaders working together and learning from incidents. The culture of patient safety has improved, we see better incident reporting rates and people feel empowered to make quality improvement changes.