4. Duties

4.1 Duties within the organisation

• 4.1.1 The Chief Executive is responsible for ensuring that:

  • a) The safety of patients, visitors and staff within the organisation is viewed as a high priority,
  • b) There are robust systems in place to identify trends and themes from incidents, complaints and claims at the earliest opportunity,
  • c) Measures are taken to ensure that the safety of patients, staff and visitors is not compromised,
  • d) There are robust systems in place to learn lessons across the organisation and cross organisationally where possible,
  • e) This policy is implemented within all areas of the Organisation through responsible Executive Directors and other senior leaders. Learning is everybody’s responsibility

• 4.1.2 The Executive Director of Nursing and Quality is responsible for:

  • a) Supporting the Chief Executive, Trust Board other Executive Directors and Service Directors in their responsibilities in implementing this policy across the Trust,
  • b) Ensuring that processes, procedures and facilities are provided for the retention, management and coordination of evidence to demonstrate compliance with this policy,
  • c) Producing appropriate highlight reports for the Quality Committee and Trust board which describes how learning is being disseminated across the

• 4.1.3 The Directors and Senior Managers have a joint responsibility to ensure that:

  • a) Action plans are discussed regularly and that themes and learning are identified and disseminated on a directorate basis,
  • b) Local services reflect on lessons learned across the organisation and make changes to practice as appropriate,
  • c) The principles outlined within this policy are implemented within their respective services/areas.

• 4.1.4 The Trust Risk Manager is responsible for:

  • a) Ensuring that there is a robust process for identifying risks from learning,
  • b) Ensuring that action plans are reviewed regularly and evaluated by the nominated committee/group,
  • c) Meeting regularly with the appropriate designated managers to discuss lessons

• 4.1.5 The Compliance and Assurance Manager is responsible for:

  • a) Ensuring that the trust wide learning bulletins are populated and disseminated throughout the organisation
  • b) Uploading key information to the learning from experience page on I-connect such as care group learning bulletins and slide decks from learning events
  • c) Ensuring that a programme of themed learning events are planned and delivered across the organisation through various media.

• 4.1.6 All staff are responsible for

  • a) Ensuring that all types of learning is captured and shared via local governance structures,
  • b) Embedding into practice any learning identified from other organisations and from within the trust,
  • c) Generating and implementing action plans as a result of an event and to record any learning so that this can be shared Trust

4.2 Committees and Groups with overarching responsibilities

• 4.2.1 The Trust Board has a responsibility:

  • a) To ensure that an analysis of all incidents, complaints and claims is undertaken on an aggregated basis to optimise the recognition of trends and themes and enable a swift response to such,
  • b) For ensuring that trends and themes are acted upon and managed effectively and that any lessons learnt through the investigation of such incidents, complaints and claims are learnt across the organisation,
  • c) To receive the aggregated data on a quarterly basis and monitor actions taken as a result of the analysis,
  • d) To support the implementation of this

• 4.2.2 The Quality Committee will:

  • a) Assure the Board that where there are risks and issues that may jeopardise the Trust’s ability to deliver excellent quality health and social care that these are being managed in a controlled and timely way,
  • b) Review the meaning, significance and learning from trends in complaints, incidents and serious incidents outlined in the Quality Digest,
  • c) Review the learning from internal reports, local or national reviews and enquiries and other data and information that may be relevant for understanding quality and safety with the Trust,
  • d) Receive reports from the patient safety group, patient experience group and the clinical effectiveness and outcomes group on a quarterly basis which highlights the key learning points which have been discussed. 

• 4.2.3 The Patient Safety Group will:

  • a) Ensure that the Trust identifies lessons for improvement and ensures these are implemented in relevant areas
  • b) Provide assurance to the Board by providing reports to the Quality Committee on a quarterly basis which highlight the key learning points that have been discussed
  • c) Receives a report three times a year on the work of the learning from experience group including key risks and issues identified

• 4.2.4 The Patient Experience Group will:

  • a) Ensure lessons for improvement are identified and that these are implemented in relevant areas,
  • b) Provide assurance to the Board by providing reports to the Quality Committee on a quarterly basis which highlight the key learning points that have been discussed.

• 4.2.5 The Clinical Effectiveness and Outcomes Group will:

  • A) Ensure lessons for improvement are identified and that these are implemented in relevant areas,
  • B) Provide assurance to the Board by providing reports to the Quality Committee on a quarterly basis which highlight the key learning points that have been discussed.

• 4.2.6 All Trust wide committees and sub groups will ensure that:

  • A) Actions Plans are in place and being monitored and risks identified, monitored and minimised,
  • B) Any learning which needs to be considered by the learning from experience group is shared.

4.3 Committees and groups with responsibility for sharing learning

• 4.3.1 The Learning from Experience Group will (see appendix C for terms of reference):

  • a) Provide a trust wide forum where all types of learning and good practice can be captured and shared across care groups/trust wide. A key function of the group is to identify thematic learning from across care groups for onward sharing trust wide. The key duties of the group include:
    • Best practice/improvements are identified from incidents, complaints, audits etc. and highlighted/disseminated across the
    • All types of learning are both captured and shared across the trust in the form of bulletins and shared at themed learning
    • There is a strong emphasis in identifying themes from the care groups which can then be shared trust
    • Learning from national reports/reviews or any other relevant sources are reviewed to ensure that all applicable learning is
    • Examples of good practice are also shared at the group, via bulletins and via the learning
  • b) Membership consists of representatives from each of the care groups and key corporate functions such as; clinical audit, health and safety, patient safety, complaints, legal services (claims, inquests and Mental Health Act)