Safety Measuring & MonitoringLearning from Past Harms

Peter WellerDirector of Quality and Governance

12th February 2015

What did we do to understand our history?Review of 2 years – Reconciliation of learning

Organisational aggregation &

systematic analysis by theme, area,

location, Individual

Third party reports

Claims and pre-action

MAPSAF & Cultural

Assessments

Complaints & PALS

Inquests

External Reviews

Safety leadership

walk rounds

Practice Governance

reviews

Contract monitoring

issues including CQUINS

Organisation Internal

Feedback – Listening to

staff

Regulatory Outcomes

Incidents

SI’s

Patient Safety Programme

Quality Improvement Strategy

Patient Experience

Strategy

Values & Behaviours OD

Strategy

Nursing & Midwifery Strategy

Leadership development & Improvement

Programme

• Moving beyond incident reports was a necessity

• Health Economy measures (Keogh)

• Patient perspective is essential