Patient Safety Incident Response Framework (PSIRF) Policy

2.1

The provision of audiology services is of low clinical risk service to patients.  The number of incidents reported are typically fewer 10 per annum.

The number of incidents that occur as a direct result of patients using our NHS audiology service (and result in an onward referral for care either by ENT or A&E) are monitored on an ongoing basis.  Incidents are reported to NHS commissioners, with whom Specsavers hold a contract, on a monthly basis as part of monthly KPI routine reporting.  These are discussed further with commissioners as required at Contract Review Meetings.

Whilst the service is low risk, the low number of reported incidents is also attributed to the robust patient safety policies and procedures that are well embedded and practiced within Specsavers.

This PSIRF policy reflects a proportionate approach to the level of risk to patients, as a result of receiving audiology goods and services from Specsavers Audiology.

3.1

The PSIRF advocates a co-ordinated and data-driven response to patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.

This policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF:

• compassionate engagement and involvement of those affected by patient safety incidents;
• application of a range of system-based approaches to learning from patient safety incidents;
• considered and proportionate responses to patient safety incidents and safety issues;
• supportive oversight focused on strengthening response system functioning and improvement.

4.1 - CORPORATE

4.11

Head of Health and Safety - Phillipe Sleet

The Head of Health and Safety for UK retail holds a corporate function and, along with the Health and Safety Team, supports all aspects of the retail business in ensuring compliance with Health & Safety requirements:

• Receiving and analysing reportable incident data
• Ensuring a proportionate response to incidents
• Mobilising a multi-disciplinary Incident Management Response Team (IMRT) to take action according to the level of incident risk (including patient safety alerts)
• RIDDOR reporting and management
• Risk management
• Adherence to health and safety/fire standards – including audit
• Communication and guidance to stores including bulletins and alerts
• Maintenance and updating of the Sharepoint Health and Safety Portal (interface with stores containing all information and reporting links)
• Updating and Issue of Health and Safety Policies and Procedures
• Reporting to and Chairing the monthly Health & Safety Committee meetings and pursuing outputs and actions

4.1.2

Head of Clinical Engagement – Annie Morris

Every store is supported by an allocated Clinical Engagement Manager (CEM). CEM’s sit within the corporate function of Specsavers and provide day to day support, guidance and training to stores, including compliance with the Audiology Notifiable Incidents Standard Operating Procedure (see section 5.1). Core functions include:

• Ensuring that clinical competencies and training requirements are met.
• Providing training – including competencies, procedures and product.
• Engaging at a national level with associations such as BSA, BAA and BSHAA, to ensure that clinical guidance is adhered to and cascaded accordingly across local stores.
• Engagement in clinical development and best practice.
• Supporting with compliance of clinical requirements as per NHS contracts.
• Involvement in clinical incident analysis and response.
• Creation of guidance documents to support compliance to clinical procedures.
• Identifying learning from incidents
• Identifying improvements – with training and guidance
• Disseminating learnings pan-organisation and revising training and policies accordingly

4.1.3

Senior Quality Standards Manager

Every store is supported by an allocated Quality Standards Manager (QSM). QSM’s sit within the corporate function of Specsavers. Specsavers has its’ own Quality Standard regime which incorporates all aspects of health and safety, incident reporting and clinical effectiveness. The Quality Standards Manager will work with each of their allocated stores to ensure that associated policies and procedures are embedded.

4.1.4

Clinical Risk and Governance Committee

Aggregated incident and complaint data for all services, including adult audiology, are reviewed at the bi-monthly Clinical Risk and Governance Committee who will from time-to-time commission a more detailed investigation of any matters of concern. The CRGC also reviews the introduction of new or changed clinical technology, procedures and operational methods and may approve, not approve or apply caveats or risk mitigations as appropriate. Matters considered by the CRGC may be added to its risk register for ongoing monitoring and future review. CRGC is chaired by the Group’s Clinical Services Director and is attended by the Chief Audiologist and NHS Services Director.

4.2 - LOCAL RESPONSIBILITIES

4.2.1

Audiology - Joint Venture Partnership Directors
Audiology Director
Optics Partners/Directors
Retail Director

The partnership Directors are responsible for ensuring that staff within the store are up to date with their mandatory training and that they are aware of what to do in the event of an incident, including immediate response, reporting and patient care.

The partnership Directors are also responsible for working with the Head of Health & Safety, Clinical Engagement Manager and store colleagues with regard to incident responses, learning and follow-up.  The Audiology Director will form part of the Incident Response Management Team, if convened.  In the Audiology Directors’ absence, another partnership Director will be assigned.

Partnership Directors are also support by nominated individuals within the Retail Support Team, to ensure that Specsavers policies are adopted and implemented.

5.1

Specsavers policies, standard operating procedures and plans, held and managed at a corporate level, are shown below.

Accident, Incident, SUI Policy

Dealing with Death Guidance

Dealing with Fire

Health & Safety Plan

Strategic Health & Safety Plan 2020-2

Audiology Notifiable Incidents Standard Operating Procedure

6.1

Our local stores operate as individual businesses and as such they have their own policies and procedures, aligned with Specsavers corporate policies.

Those impacting and relating to Patient Safety are included in this section.  This includes ensuring that onward referral to secondary care/GP for identified contraindications happen in a timely manner with an urgency appropriate to the identified condition.  It also includes effective triage/screening processes are in place to ensure that patients are being seen in the correct specialty and to ensure that they do not need urgent/non-urgent onward referral.

The Patient Pathway Policy describes the interaction with every patient, ensuring their wellbeing and safety.

6.2

Health & Safety Policy

Referral Triage

Onward Referral

Local Risk Register

Second Opinion Policy

Patient Pathway

7.1 - GUIDANCE AND SUPPORT

7.1.1

Specsavers has a Health & Safety Hub and Reporting Portal on the Sharepoint intranet site.  Every store where NHS audiology services are delivered has access to the portal.  Guidance and support is readily available in the event of an incident, from reporting through to incident management and follow-up.  All associated policies and procedures are included in the hub.

The hub provides links to a dedicated health and safety team that will support and guide through any incident and emergency and is available 24/7.

7.2 - HEALTH & SAFETY COMMITTEE

7.2.1

The Health and Safety (H&S) Committee meets on a monthly basis, to discuss the previous months’ incidents, accidents and near misses, if any. The purpose of the Health & Safety Committee is to advise, report and assure the UK & ROI Operating Board that effective arrangements are in place to monitor and review the implementation of the Specsavers Group H&S Policy and other supporting policies, documentation and training & arrangements.  The H&S Committee ensures participation of key stakeholders in the prevention of health and safety incidents within optics, audiology and domiciliary businesses within Specsavers Group in the UK and ROI.

The H&S Committee will make recommendations to the UK/ROI Operating Board on in relation to strengthening and developing health & safety across the Specsavers Group.

Please see Terms of Reference.

7.3 - INCIDENT RESPONSE MANAGEMENT

7.3.1

The Health & Safety Manager will determine a proportionate response to incidents on a case-by-case basis.  If an incident requires action and response, an Incident Management Response Team (IMRT) will be mobilised, to include key individuals (including the store Audiology Director) as identified by the Health and Safety Manager.  The IMRT will analyse the incident report to ensure all the correct actions have been taken, learnings noted and shared and preventative measures are put into place.

7.3.2

Where a RIDDOR incident is reported, Specsavers has an agreed approach that applies to all UK Specsavers business operations (including business support, stores an manufacturing and distribution) upon notification of an incident:

The Health and Safety Manager will notify the HSE in line with statutory legal requirements, this will be done via Ligtas.  The Health and Safety Manager will appoint Ligtas to arrange a store visit, in order to carry out an accident investigation into what happened.  The store will also receive an out of sync health and safety audit.

If there are any learning or common themes that are discovered from these investigations the Health and Safety Manager will communicate this via the most appropriate and effective method, that will circulated throughout the stores network.

7.3.3

Actions to be taken will include the ensuring the wellbeing of individuals affected by the occurrence, including patients, families and carers.  Engaging with patients, families and staff following a patient safety incident is of utmost importance.  Typical the Audiology Director will engage with the patient following an incident within an appropriate timescale and in an appropriate manner, in accordance with the type and severity of incident.  Please see section 5.1 Audiology Notifiable Incidents Standard Operating Procedure.

Specsavers recognises that learning and improvement following a patient safety incident can only be achieved if supportive systems and processes are in place. It supports the development of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff). This involves working with those affected by patient safety incidents to understand and answer any questions they have in relation to the incident and signpost them to support as required.

Timeframes for learning responses will depend on the urgency and level of risk associated with the required change.  The Health & Safety Committee will allocate timescales to actions along with the accountable person.

7.3.4

Specsavers Group is a global organisation which providers optics, enhanced ophthalmology services and audiology services.  Specsavers has an extensive network of stores.  Learning is channelled via the Health and Safety Committee and cascaded throughout Specsavers Group, to ensure a collaborative response to health and safety learning and improvement.