7. Organisational process for implementing change as a result of learning

7.1

The Trust is committed to learning lessons and promoting improvements and making changes in practice using all of the information and experience available. Information that is used derives from three main sources:

• 7.1.1. Learning from local events and experiences, which involves:
  • a) Analysing individual   and    aggregated    information   relating   to    incidents (including, Serious Incidents), complaints, claims
  • b) Identifying trends, causes and impacts
  • c) Sharing the learning across the organisation and using it to promote improvements in practice as described in Appendix A – Learning from local events and experiences and Appendix B – Learning from external assessments, reviews, national enquiries, recognised best practice and across

• 7.1.2 External assessments, reviews, national enquiries and recognised best practice; which involves:

  • a) Reviewing and understanding best practice standards and requirements
  • b) Allocating responsibilities for implementation
  • c) Developing and implementing actions plans to address identified

• 7.1.3 Cross organisational learning which is facilitated by:

  • a) Reporting serious adverse events through the STEIS reporting system providing a further opportunity to contribute to cross organisational
  • b) Peer review of Serious Incidents with local commissioners including sharing findings and lessons learned from investigations
  • c) Using the information system which links to the National Patient Safety Agency (NPSA), NHS England, National Learning and Reporting System (NRLS) to ensure that incidents reported within the organisation are fed into a central system and further analysis and trend identified performed at a National level to enable National learning
  • d) Extracting key learning themes identified on Datix for serious incidents and complaints to identify where further action may be
  • e) Membership of regional Clinical Audit Network supported by Healthcare Quality Improvement Partnership – South East Clinical Effectiveness Network (Member of National Audit and Governance Group supported by Department of Health/Quality Board)
  • f) Working with organisations across the healthcare community including local authorities and CCG’s.