The new Congenital Heart Disease Standards require that the Network operates within a governance framework that includes:
Regular meetings of the wider network clinical team, held at least every six months, whose role extends to reflecting on mortality, morbidity and adverse incidents and resultant action plans from all units. (Standard F3, Congenital Heart Disease Standards & Specifications, NHS England, May 2016)
It is important to note that this requirement does not replace individual provider’s responsibilities to report and act upon incidents within their own institution.
The reporting to the Network should be seen as additional to, not a replacement of, local reporting and action.
Incidents should therefore be reported to the network where they affect cross-provider care or pathways, are significant in nature, or where there may be wider learning for other network partners. (See document for full trigger list).
- Incidents should be investigated locally, following local Trust / Health Board procedures. The network management team may identify particular opportunities for wider learning within the network and therefore ask that the local investigation considers and reports back on these.
- Learning from investigations should be shared with the network management team
- Where required, the network team may inform external stakeholders (e.g. commissioners and regulators), but this should not supersede or replace the individual provider’s responsibilities in this regard
- Investigation of an incident may identify a network risk. This should be logged in accordance with the network Risk Management procresses
Investigation and broader learning
- On notification of an incident, the network management team will log this and capture any learning from the incident
- On a quarterly basis, a summary of incidents and learning will be collated and presented to the Network Board Meeting
- Analysis of any themes, common learning will be used to inform changes in practice and approach in the network. This will be communicated to all providers following the Network Board meeting.
- Responsibility for taking forward local action remains with the individual provider Trusts. The network management team will be responsible for coordinating actions across and between providers, or for those actions that need commissioner input
Full details of our Morbitidy and Adverse Incident Reporting policy can be found here.
For information on the management of serious incidents and never events within specialised commissioning please click here for the standard operating procedure.