Primary Care Trust fined £10,000 after patient falls 4 metres from a window

North East Essex Primary Care Trust has been fined £10,000 and ordered to pay costs of £4,972 after a vulnerable and partially-sighted patient it was responsible for fell 4.3 metres from a first floor window at Clacton & District Hospital.

The retired 68-year-old suffered a blow to the head and broke his pelvis, shoulder and coccyx in the fall in March last year. The court heard he was known to wander on the ward and had previously suffered four strokes, which had left him mentally and emotionally impaired.

The Health and Safety Executive (HSE) prosecuted the Primary Care Trust (PCT), based at Colchester Primary Care Centre, in Turner Road, Colchester, over the incident. Today representatives of the PCT appeared at Harwich Magistrates’ Court and admitted breaching Section 3(1) of the Health and Safety at Work etc. Act 1974.

The court heard that the patient was staying in the St Osyth Priory Ward at Clacton & District Hospital, in Tower Road, Clacton-on-Sea. At around 10.20pm on Tuesday 4 March 2008, he had wandered into the ward’s first floor day room and fell from an open window to the ground below.

The window was able to open 254mm, but since 1989 NHS standards have required such a window to only open to 100mm by fitting a window restrictor.

Shortly before the incident the PCT was required by the Department of Health to review its window restrictors and identify any that were missing, damaged or defective. This review was not carried out.

HSE Inspector Kim Wicks said:

“North East Essex Primary Care Trust failed in its duty to ensure the health and safety of this retired gentleman, who was left severely injured after his fall, which should never have happened.

“Today’s case should serve as an alarm bell, reminding all Primary Care Trusts how vitally important it is to carry out full risk assessments and act on the findings. The risk of vulnerable patients falling from windows above ground level is well known and there have been a number of similar cases. Equally, the control measures, in this case window restrictors, to prevent this risk are easy to fit and maintain.

“All PCTs must ensure they adhere to recognised NHS safety standards – they are there for a reason. If North East Essex PCT had done so this unfortunate incident could have been avoided.”

Patients at risk from mis-management of medicines

According to a new report by the Care Quality Commission (CQC), patients could be at risk unless the management of medicines between services such as GP practices and hospitals is improved.

The report – Managing patients’ medicines after discharge from hospital – looks at how well patients’ medication is managed after patients leave hospital.

The CQC visited 12 primary care trusts (PCTs), and surveyed 280 of their GP practices and found some evidence of good practice, but also found the following concerns:

• Information shared about patients moving between GPs and hospitals is often patchy, incomplete and not shared quickly enough
• GP patient records are not  always updated by clinical staff
• Too few patients are offered discussions with their GP about managing their medication
• GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

CQC Chief Executive Cynthia Bower says: “There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.”

Download the report Managing patients’ medicines after discharge from hospital here.

NHSLA publishes timeline setting out history of its standards and assessment

A useful timeline has been published by the NHS Litigation Authority as a Powerpoint file.

It sets out the key internal events that have marked the development of the NHSLA risk management standards and assessments, together with the external events that have influenced them from the establishment of the NHSLA in 1995 through to the present day.

Download the timeline here.

NHSLA and NICE joint statement about NICE guidance and risk management

The NHS Litigation Authority (NHSLA) and the National Institute for health and Clinical Excellence (NICE) have issued a joint statement about how compliance with NICE guidance can help trusts manage risk and optimise their resources.

Compliance with NICE guidance is the focus of criterion 5.8 of the NHSLA risk management standards. This requires organisations to have in place approved documentation (Level 1) which describes the process for ensuring that agreed best practice as defined in NICE guidance is taken into account in the context of the clinical services provided by the organisation, that is implemented (Level 2) and monitored and, where monitoring has identified deficiencies, there is evidence that recommendations and action plans have been developed and changes made accordingly (Level 3).

For higher level assessments, every year NICE will provide the NHSLA risk management assessors with a revised list of manual-specific clinical guidelines that will be assessed against during the financial year. Topics will be selected by NICE based on its assessment of those that are current, relevant and could reasonably be expected to have been discussed and implemented within the organisation. The list of clinical guidelines will be included at the back of the specific manuals so that organisations and assessors are aware of the topics selected each year. The assessor will select one clinical guideline from the relevant list to test compliance with the requirements of Criterion 5.8. For interventional procedures the organisation will be asked to indicate the interventional procedures guidance that has been implemented and the assessor will select one from those to test compliance with the requirements of Criterion 5.8.

Download the full joint NHSLA/NICE statement here.

BMJ research paper adds to evidence of increased patient mortality associated with trainee doctors

A recent Healthcare Governance Review post focused on Dr Foster’s research into the association between increased patient mortality and the August intake of new junior doctors (click here).

The British Medical Journal (BMJ) has published a research paper describing a study that sought to determine whether an increase in the rate of undesirable events occurs after care provided by anaesthetic trainees at the beginning of the academic year.

The ‘retrospective cohort’ study was carried out at the Alfred Hospital, a University affiliated hospital in Melbourne, Australia. The study used administrative and patient record data and the participants involved 19,560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000).

The study found that “The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.”

The study concluded that “Strategies to minimise the rate of undesirable events at the beginning of the academic year should look at improving trainees’ orientation and integration during the first weeks, by developing, for example, mandatory introductory courses, hospital settings’ visits, and interprofessional meetings and, beyond all the rest, by avoiding residents’ involvement in clinical tasks from the first day. The orientation period could also include close one to one supervision, particularly when cross cover work is done in different hospital settings. The systematic use of written documentation of standard working practices should be encouraged to minimise the loss of tacit knowledge associated with staff turnover. Crew resource management programmes such as those developed in aviation and now increasingly introduced in the healthcare environment could be used to improve team coordination and interprofessional collaboration. Finally, early training sessions in simulators could be scheduled to favour rapid improvements in junior trainees’ technical skills.”

The full research paper Rate of undesirable events at beginning of academic year: retrospective cohort study can be freely downloaded here.

Survey of UK surgeons indicates patients are less safe with European Working Time Directive

The Royal College of Surgeons has published the results of its survey into the impact of the introduction of the European Working Time Regulations (EWTR) on surgeons. The results are based on responses by 900 surgeons across the UK and indicate that there is clear evidence that patients are much less safe in the NHS since the August introduction of the 48 hour working limits. The results included the following:

· 64 per cent of all respondents thought quality of care had worsened due to the EWTR.

· More than half of consultants believe compliance with EWTR has been achieved at the expense of patient safety (overall 44 per cent of respondents agreed).

· A third said handover arrangements are inadequate in their hospital and 23 per cent said they cannot stay involved in all stages of individual patients clinical care that require their expertise.

· 62 per cent of surgeons said they were not working a truly compliant 48 hour week with 70 per cent estimating they worked more than 48 hours – with these surgeons estimating they averaged between 55-60 hours a week.

· A quarter of respondents said that other professionals in the healthcare team are acting up to cover tasks previously done by surgeons and 43 per cent said they are covering rota gaps in other areas of their own hospital to keep services running.

Download the summary results here.

Lessons from a review of five London hospital fires and their management

NHS London has published  a review of five significant fires during 2008/09 at NHS sites in London, which required the evacuation of part or whole of the building. Any evacuation of a large commercial building is difficult – coping with a facility as complex as an NHS site, complete with sick and recovering patients, staff and visitors presents further challenges.

The events of 2008/09 proved that with good teamwork, leadership and planning, a safe, successful evacuation of a healthcare facility is achievable. NHS London states that it is imperative that every NHS organisation in London has tried and tested full site evacuation plans.

London’s experiences during 2008/09 demonstrate the critical importance of being prepared for emergencies. The report shares lessons learned from the five significant sires to support colleagues in the wider NHS when developing local plans.

The detailed lessons identified from the five events detailed in the report are clearly laid out in Appendix 2 to provide a checklist for planners and managers across the health service. The report will help to inform the ongoing development of the Department of Health guidance – planning for the evacuation and shelter of people in healthcare settings.

Healthcare Governance Review suggests that NHS boards assure themselves that management in their organisations are well prepared for emergencies and, in particular, have tried and tested full site evacuation plans in place.

Download the report Review of five London hospital fires and their management here.

Credit: Thanks to Peter Aldridge, fire safety manager at Leeds Teaching Hospitals NHS Trust, for bringing this report to our attention.

Governance of health and safety – the need to ensure safe systems of operation and to carry out risk assessments

David Halcki MBE (David.Halicki@btinternet.com), independent health and safety consultant and former NHS safety professional, believes that NHS boards and managers should learn lessons from the following industrial laundry incident. In particular, he is urging boards to ensure that NHS organisations have safe systems of operation in place and carry out risk assessments both in relation to any laundry services they might have, and in relation to wider organisational health and safety matters.

The Health and Safety Executive (HSE) is urging laundry companies to ensure that they have safe systems of operation in place and carry out risk assessments after a worker was left in a coma, following an incident at a factory in Balham, Wandsworth. This follows the successful prosecution (Thursday 24 September) of a major UK laundry company at Southwark Crown Court, following an incident in October 2007. OCS Group UK Limited of Limpsfield Road, Sanderstead in Surrey was fined £80,000 and ordered to pay costs of £33,059, after pleading guilty to breaching section 2(1) of the Health and Safety at Work etc Act 1974, after Joseph Pathmananthan, a worker at the site, was injured in a serious incident.

OCS Group UK Limited provides commercial laundry services at industrial processing plants across the UK, including Balham. This plant had approximately 150 workers. 

On 2 October 2007, Mr Pathmananthan, a 61 year-old employee from Sutton in London, was working at the company’s Boundaries Road site in Balham. He was repairing the hopper unit which loads roller towels into the top of a continuous batch washer, which is an industrial washing machine costing more than one million pounds. The hopper unit needed repairing after a towel had become entangled in a lifting belt. After several different methods had been used by Mr Pathmananthan and four other colleagues to dislodge the towel, he entered the hoist’s protective cage to continue to try to remove the towel. Mr Pathmananthan was standing underneath the suspended large steel hopper. As the towel became free the hopper fell two meters onto the victim, crushing him. He suffered from multiple broken bones and internal injures and was in a coma for 19 days.  He stayed in hospital for three months and has not been able to return to work for two years since the incident.

OCS Group UK Ltd carried out an internal investigation into the incident and almost all the blame fell on a number of employees on the Balham site, including the victim who was disciplined. Despite the HSE subsequently prosecuting OCS, the company’s own internal investigation made little criticism of the company’s policies or of senior management. The HSE investigation showed that OCS Group UK Ltd did not have a sufficiently effective system for ensuring the machinery was safe to be operated and maintained, and that there were no checks on the machinery after its repair.  Also, the Balham site engineering team had not been provided with a manual which would have clearly shown how to raise the hopper safely for someone to work beneath it.  The court heard that two years prior to the incident, an HSE Inspector had attended the site and had identified that Mr Pathmananthan needed more support.

The HSE gave direction on necessary improvements including the need to risk assess the continuous batch washer, but there was no evidence this had been followed by OCS Group UK.  The HSE also found the site had inadequate controls in place to stop people slipping and tripping and that the movement of vehicles at the busy site was disorganised and dangerous.

While sentencing the company, Judge Taylor criticised OCS Group UK Ltd for what she said was a systemic failure and its complacency during monitoring. If the company had not pleaded guilty at the earliest opportunity Judge Taylor, said the fine would have been £40,000 more. Andrew Verrall-Withers, Health and Safety Inspector, said: “I was pleased the company co-operated with the investigation and made good efforts to improve after the incident, but I was surprised and disappointed that their own internal investigation failed to identify so much of what the company had got wrong.  “I hope this case sends out a message to other companies, including large ones, that it is vital they make sure that they are protecting their employees effectively. It is no good to anyone if problems are only found after it is too late.”

Liverpool trust fined £48k for legionella ‘complacency’

The Liverpool Heart and Chest Hospital NHS Trust was ordered to pay nearly £48,000 following an HSE investigation at the NHS Trust’s hospital on Thomas Drive, Liverpool.

The investigation found unsafe levels of legionella in the water supply system for the showers, baths and sinks at the hospital. But it was not able to conclude whether two patients, who both contracted legionnaires’ disease before their deaths in early 2007, were infected at the hospital or elsewhere.

Liverpool Magistrates’ Court heard that the NHS Trust had stopped testing the water supply for legionella, despite high levels of the bacteria being found in the Audrey Leigh wing in May 2002.

HSE criticised the NHS Trust for failing to put suitable control measures in place, and senior management for failing to take responsibility for overseeing the control of the bacteria.

The NHS Trust pleaded guilty to breaching Sections 2(1) and 3(1) of the Health and Safety at Work etc Act 1974 by putting employees and the public at risk. It was fined £35,000 and ordered to pay costs of £12,862 at Liverpool Magistrates Court on 8 October 2009.

HSE Inspector Kevin Jones said:

“It is almost beyond comprehension that Liverpool Heart and Chest Hospitals NHS Trust became so complacent about legionella in the water supply system. We were astonished to discover that the NHS Trust’s management team took a decision to stop testing for the bacteria. The hospital’s water supply system was clearly at risk from legionella and so regular tests should have been carried out.

“The NHS Trust ignored the recommendations it had been given by a specialist contractor to control the levels of legionella in the water system. No one took, or was given, responsibility for managing the bacteria, and suitable control measures were not in place.

“Hospital patients are at more risk than most of being infected with legionnaires’ disease. It’s therefore vital that NHS Trusts treat the risks seriously to help prevent deaths in the future.”

Health Care Risk Report October 2009

Swine flu is continuously on the NHS agenda at the moment, and Health Care Risk Report presents a different view this month. Professor Hilary Pickles, a public health and risk expert, points out that lessons can be learned from the rush to set up antiviral distribution centres over the summer – not least that the distraction it caused posed a risk to normal NHS business. 

Health Care Risk Report editor Pat Anderson has opened a new LinkedIn group for HCRR readers, contributors and editorial board members. Please take a look, join and consider contributing to the forum. Click here.

 Also in the October issue of Health Care Risk Report :

 - how GPs reacted to using the Primary Care Trigger Tool to identify harm in their practices, by Dr Richard Jenkins and colleagues from the NHS Institute for Innovation and Improvement

- whether “Seven steps to patient safety” is too far for GPs to climb, by Dr Tayza Aung

- how the NPSA plans to take forward learning from serious incidents, by chief executive Martin Fletcher

- patient safety in the Netherlands and Pennsylvania, USA

- the Department of Health’s new consent guidance and changes to Lasting Power of Attorney forms.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

KPMG view on the board’s oversight of risk

An interesting article by Henry Keizer, Global Heald of Audit, KPMG International, considers the board’s role in the oversight of an organisation’s risks.

According to Keizer, “…we’ve reached an inflection point for corporate governance, and that effective oversight requires the exercise of healthy skepticism…..[and]….the ability—and willingness—of directors to ask that second and third follow-up question about a risk, or about the risk-management process, is a vital sign of how healthy the board’s risk conversations are—and how firm a handle it has on risk oversight.”

He believes that a key question for every board is “whether any single committee— such as the audit committee, or even the full board—has the time, resources, and expertise to effectively oversee the full range of risks that the [organisation] faces.”

Keizer suggests that strengthening board oversightof risk should include:

- being clear about the board’s oversight objectives

- working with management to agree on the types of risk information a board requires

- ensuring that the culture encourages directors to question, challenge and test management

- invite the right people to the board’s conversations about risk

- ensure that risk oversight responsibilities of teh full board and its committees are clear.

Read the full article here.

Thinking about risk – HM Treasury guidance

HM Treasure has published three documents concerned with risk for boards and risk management practitioners. This is not new guidance, so some readers may already have seen it.

According to HM Treasury, it is essential that the board’s attitude to risk is communicated to the whole organisation and applied in decision making regarding the prioritisation of policies and the funding that goes with them.

The HM Treasury guidance provides an overview of the concept of ‘risk appetite’ and aims to help boardss refine their application of their organisation’s risk appetite so that risk judgements are more explicit, transparent and consistent, in the hope that it will enable boards to have the best opportunity of achieving their corporate goals.

The three documents are:

- Thinking about risk, Managing your risk appetite: A practitioners guide

- Thinking about your risk: Setting and communicating your risk appetite

- Thinking about risk – Managing your risk appetite: Good practice examples

The guidance can be freely downloaded here.

Risks to board members? This one takes the biscuit!

According to the Daily Telegraph (8 September 2009), a new survey has found that more than half of all Britons have been injured by biscuits ranging from scalding from hot tea or coffee while dunking or breaking a tooth eating during a morning tea break, with at least 500 people landing themselves in hospital.

The custard cream was found to be the worst offender. It beat the cookie to top a table of 15 generic types of biscuit whose potential dangers were calculated by the Biscuit Injury Threat Evaluation (BITE). Custard creams get a risk rating of 5.63, this compared to 1.16 for Jaffa cakes, which was the safest biscuit of all in the evaluation.

The full results of the BITE study were as follows:

Custard Cream 5.64
Cookie 4.34
Choc Biscuit Bar (eg: Rocky) 4.12
Wafer 3.74
Rich Tea 3.45
Bourbon 3.44
Oat Biscuit 3.31
Digestive 3.14
Ginger Nut 2.99
Shortbread 2.90
Caramel Shortcake 2.76
Nice Biscuit 2.27
Iced Biscuits/Party Rings 2.16
Chocolate Finger 1.38
Jaffa Cakes 1.16

Healthcare Governance Review believes that board members, and anyone in healthcare generally, might like to consider the risks associated with various biscuit types. Non-executive directors in particular might like to challenge management as to their choice of biscuits for board meetings. Taken to its logical conclusion, the issue of whether only Jaffa cakes should be available should be debated – indeed, the issue of whether people are allowed to take biscuits into the organisation given the risks involved might also be a matter for debate. Perhaps all healthcare organisations should ban staff from taking their own biscuits in to work on the grounds that they could cause injury? Or would this be regarded as truly ‘taking the biscuit’?

Read the full Daily Telegraph article here.

New book – Enhancing Patient Care: A practical guide to improving quality and safety in hospitals

This is, perhaps, THE most practical and useful book on patient safety and quality of care available today. Every hospital and anyone involved in patient care, clinical governance, quality, safety and/or risk management should have a copy. And any educational programme covering the subjects mentioned should commend this book as a key text.

Written by Australian clinicians, Associate Professor Alan Wolff, Director of Medical Services, and Sally Taylor, Clinical Risk Manager and former midwife (see photo), and formally launched by the Victoria Health Minister on 31 August 2009 (click here), this is a commonsense guide to quality improvement and risk management in hospitals. The book is based on their work, over many years, in the Wimmera Health Care Group in Victoria, Australia. Their experience at a regional hospital has led to a pragmatic framework that guides other health services through the relevant evidence and theory, down to finest details on practical quality, safety and risk management. 

Whilst the book has been described in terms of “help[ing] improve practices and patient outcomes in hospitals throughout Australia” there is little, if anything, in the book that cannot be applied internationally. Enhancing Patient Care will be of particular use to anyone who wants to set up or improve a quality improvement and risk management program, regardless of size and budget.

  

Assoc. Prof. Alan Wolff and Sally Taylor

The book contents include:

- Explanations of clinical governance, quality improvement and risk management
- How to detect adverse events and risks to patient safety
- A practical framework to prevent adverse events and reduce risks
- How to develop a quality improvement and patient safety culture
- A step-by-step guide to implementing a clinical risk management program in your health service
- How to develop a clinical risk management program in a small hospital

Interested readers can download a PDF preview of the book, which includes the detailed contents pages, a diagrammatic description of the Wimmera quality improvement and risk management model, and a Foreword by Profesor Bruce Barraclough, Chairman of the International Society of Quality in Healthcare (ISQua), here.

The book costs 50 Australian dollars (approx. 30 British pounds) and can be purchased from the bookshop of the Medical Journal of Australia, here.

Update on trust compliance with NHSLA risk management standards

The NHS Litigation Authority (NHSLA) has published its annual report and accounts for 2008/09. Amongst other things, the report provides a helpful update on trust compliance with the NHSLA’s risk management standards.

There are separate risk management standards incorporating organisational, clinical and health and safety risks for NHS acute, mental health & learning disability, ambulance and primary care trusts and independent sector providers of NHS care. Each set of standards contains five individual standard areas: Governance; Competent & Capable Workforce; Safe Environment; Clinical Care; Learning from Experience. Within each standard, there are ten equally weighted criteria or risk areas. Each risk area is addressed through an ongoing programme of assessment at three distinct, progressive levels:

• Level 1 – documentation (policy)
• Level 2 – implementation (practice)
• Level 3 – monitoring and improvement (performance).

To achieve compliance, organisations must pass at least 40 out of the 50 criteria with no fewer than seven passes in any standard. NHS trusts receive increasing discounts, ranging from 10% – 30%, on their contributions to our risk pooling schemes as they progress from Level 1 to Level 3. The results of assessments are published on the NHSLA website in Factsheet 4 on a monthly basis, as well as copies of assessment reports.

A range of tools are available including handbooks containing guidance and reference sources in the support of the standards, an electronic evidence template to enable organisations to conduct a self-assessment and to accompany evidence submitted for assessment, and template documents to assist organisations in drafting local policies to manage risks.

The new Risk Management Standards for Acute Trusts were introduced in April 2007. All NHS acute trusts (other than one new organisation) have now been assessed against the standards and by the end of March 2009, 52% had achieved the higher levels. The results of all assessments are shown in the chart below.

Download the NHS Litigation Authority’s 2008/09 Annual Report and Accounts here.

NPSA consultation on serious incident reporting system

The National Patient Safety Agency (NPSA) is consulting on The National Framework for Reporting and Learning from Serious Incidents Requiring Investigation. The draft framework provides a consistent definition of a serious incident, clarifies roles and responsibilities, draws together legal and regulatory requirements, information on timescales and signposts tools and resources that support good practice. The deadline for responses is 13 November 2009.

Download the consultation document here.

Improving strategic risk management arrangements – Audit Commission diagnostic and improvement tool

The Audit Commission has launched a new risk management diagnostic tool for use across all sectors which focuses on risk leadership, partnership risk management and risk related outcomes.

‘Risk it to make it’ is based on tried and tested frameworks devised by HM Treasury and contains information on what represents excellent and strongly improving performance through integrated risk management.

According to the Audit Commission, this new tool enables an organisation or partnership to:

- know how well its risk management arrangements are working

- improve integrating risk management with its corporate business processes

- target improvement action especially on risk leadership and outcomes.

Airedale NHS Trust was involved in the pilot of the tool. According to Adam Cairns, Chief Executive,”The Trust benefited immensely from our involvement in this pilot. We gained an external assurance of our strategic systems and processes, and areas for further work were identified. NEDs and staff including medical representatives involved in the structured interviews and workshops appeared to enjoy their involvement and their ability to affect thinking on this key area for the Trust.”

The tool is deployed by the Audit Commission to its clients on a ‘commercial’ basis. For further information, click here.

NHS boards and swine flu – the situation in England

On 2nd July the Department of Health (DH) wrote to NHS organisations setting out guidance for managing the swine flu pandemic.

Despite the fact that swine flu (H1N1) appears to be of little real threat to the majority of the population, nevertheless the demands place on the NHS by those with, or suspected to have, swine flu are likely to be immense.

The DH guidance Swine Flue Pandemic: From containment to treatment – Guidance for the NHS sets out a number of requirements for NHS boards, viz:

- each NHS Board should appoint a full time director level lead dedicated to flu preparedness and resilience with immediate effect. This can be a single individual or shared between directors but must provide visible, full-time, senior leadership and ensure a well-resourced team on this issue through the months ahead

- each NHS Board is requested to take reports on progress towards their readiness assessment against the Department’s HR and Surge guidance to their July and August meetings

- each NHS organisation takes part in the September nationally devised and SHA and HPA-organised resilience testing and exercise programmes to validate Pandemic Flu Plans and Winter Readiness Plans. Board level attendance, including from NHS CEs, is expected at these events

- each strategic health authority (SHA) Board should assess the robustness of NHS organisational and local system Flu Pandemic Plans and sign off that assurance on behalf of the Department of Health

- each PCT Board should demonstrate visible leadership through effective dialogue with local LMCs and individual practices.

Download the full DH guidance Swine Flue Pandemic: From containment to treatment – Guidance for the NHS  here.

Improving clinical governance in Out of Hours services – ECRI Institute’s INsight Systems Assessment

Out of Hours (OoH) services now provide patient care for 70 per cent of the patient week. With this comes the clinical governance challenge to ensure that the quality of service remains as high as ever, having reduced any exposure to unnecessary risks. Recent tragic events in the provision of Out of Hours services remind us that this is often a very difficult and ever present challenge for the commissioners and providers of these services.

This is why the ECRI Institute, a major non-profit health services research agency, and sponsor of Healthcare Governance Update, has developed its dedicated INsight ™ Systems Assessment Programme for the use of Out of Hours services. An INsight system assessment is a multidimensional organisation-wide patient safety, risk and quality systems assessment. It helps an organisation determine if its systems are robust, reliable and effective enough to support its governance responsibilities to ensure quality and meet the national standards.

More information about INsight System Assessment for Out of Hours Services is provided here.

ECRI Institute Alerts Tracker launched in primary care

ECRI Institute, a non-profit health services research agency and sponsor of Healthcare Governance Update, has recently launched in primary care its Alerts Tracker web based system for tracking action on safety alerts. Although the system has been widely used by secondary care providers in the UK and around the world for many years, it has recently been modified for use in primary care.

In launching Alerts Tracker for primary care, Dr David Watson, ECRI Institute Vice President UK & Europe, explained that primary care has just the same needs to ensure that the loop is closed effectively once a safety alert has been notified. Also, in ECRI’s experience it’s one thing to receive a safety alert but to get it into the right hands and get the necessary assurance that action had been taken was quite a different matter. He went on to say that many PCTs were seeing the advantage of the system as it reduced the need for lots of administrative time in chasing up action.

For further information click here –  Alerts_Tracker_HGR