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Incident Management 2016

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Medical Development Team

on 20 June 2016

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Transcript of Incident Management 2016

Incident Management 2016
MDT Workshop, January 28th 2016
Wrap-Up
2016 Policy Updates
Incident Management Training Package
2014-2015 System Implementation
Where do we think our programmes are?
What does the data show?
2015 Workshop
2016 Updates
2014 Policy: What was challenging?
How?
Competencies
Global Roll-out
Module 1
Module 2
Progress
Shortcomings
Clarify
requirements
Simplify
content
Increase
impact
Clinical Effectiveness

Client Safety

Client Experience
Learn

Improve

Prevent Recurrence
Success factors:
Leadership
MDT support
Training Prezi
Barriers:
Motivation
Cultural barriers
Ownership
What if...
What factors impacted implementation?
Purpose:
EMBED
practices


Delivery method
Out-of-the-box learning sessions
Modular Approach
Module 1
Module 2
Continuous Practice Sessions
Module 3
Service Delivery
Programme Specific
Support Office
1. Define incidents
2. Reasons for reporting
3. Learning culture
Module 1
Module 2
Continuous Practice Sessions
Module 3
Service Delivery
Programme Specific
Support Office
4. Delivering feedback to teams
5. Communicating to programme
1. Risk Grading
2. Notification forms
3. Timelines
4. Investigation process
5. RCA
1. Implementing action plans
2. Data management
3. Creating action plans
4. Escalation
5. Analysis
6. Disseminating learning
Competencies
1. Define incidents

2. Reasons for reporting

3. Learning culture
Activities
Let's Try!
Enabling Culture
1. Scenarios

2. Brainstorm

3. Values clarification

4. Blame vs. Gain

5. Experiences w/ Feedback

6. Communication case studies

7. Culture of safety case study

8. Programme culture evaluation


Have you ever been blamed?
Blame vs. Gain
Competencies
Activities
Let's Try!
1. Risk grade

2. Respond

3. Forms

4. RCA
1. Experiences

2. Risk rating scenarios

3. Completing INF/PRIF


Risk Rating
Root Cause Analysis
Module 3
Competencies
Activities
Let's Try!
1. Action plans
2. Data
3. Learning
1. Multiple reactions
2. Brainstorming actions
3. Communicating findings

4. Action Plan Essentials
5. Matching actions to RCA
6. Action plan weaknesses

7. Master Incident File
8. Sample database
9. Safety alerts
Incident Notification Form
Sample Database
let's start by bringing our client out into the real world....
i'm on my way to marie stopes!
daisy smith
i made it!
but where are the service providers?
marie stopes outreach here today!
daisy smith
faith smith
i have been waiting 2 hours already!
phew! we've made it!
nurse
driver
tick tock...
we must get started right away, there are so many clients waiting!
i will start doing counseling and taking consent while the doctor sets up!
daisy smith
faith smith
i'm 16 years old, and don't have any children yet. i also don't want any kids anytime soon! that's why i'm choosing get have an IUD inserted today. i wish that your team spoke my local dialect better though, i'm not very comfortable in english!
i'm 35 years old and already have 5 kids. i don't want anymore!! that's why i'm getting a tubal ligation today.
counseling and consent
marie stopes
waiting
staff arrives
getting organised
daisy's consent and medical history
nurse
counseling and consent
faith's consent and medical history
nurse
immediately after counseling
nurse
doctor
here are all the client files and consent forms
great!
i'm all set-up. let's get started!
doctor
ms. smith, please come for your procedure!
faith's consent and medical history
daisy smith
coming!
5 minutes later
nurse
daisy smith!
we're ready for you!
daisy smith...?
hmm... she
must have gone home?
community health worker
your tubal ligation is all done!
daisy smith
at the outreach site
getting started
the procedure
after the procedure
the client
MSI
beginning...
DAISY SMITH
Phew! We made it!
Quarterly Report

Safety alerts

Support & awareness
Under-reporting
Investigation Quality
Incidents by Channel
Incidents by Programme

4. RCA Steps

5. Daisy Smith RCA

6. RCA case studies
Full transcript