Patient Safety Incident Investigator

Job summary

We have an exciting opportunity to work as a member of the Patient Safety Incident Investigation Team. The Patient Safety Incident Investigator is a member of the Corporate Patient Experience, Risk and Legal Services (PERLS) team. The post holder will lead and be responsible for undertaking complex investigations into serious incidents / never events within the designated timescales reported to the NHS Wales Executive

The Patient Safety Incident Investigator will act as an expert advisor and investigator to the Service Delivery Groups in regard to patient safety incident investigations. This is in support of positively impacting organisational learning and culture. The Patient Safety Incident Investigator will provide corporate assurance and scrutiny of incident reporting, investigation and learning

Main duties of the job

to support the Lead Patient Safety Incident Investigator to enable the delivery of an efficient and effective high quality service to work autonomously, leading on complex investigations where there has potentially been serious harm to patients and when a Never Event has been identified

o to undertake investigations and to complete an investigation report within the designated timescales reported to the NHS Wales Executive

About us

We believe staff are our best asset and wewant you to be happy and confident about starting your career here in Swansea Bay University Health Board.

As one of the biggest healthcare groups in the UK we can offer a wealth of professional training and development opportunities in an innovative, forward-thinking organisation.

You might be a nurse ordoctor, maybe you specialise in a health science/therapy or can offer skills in one of our support services - wehave a job for you.

There are also apprenticeships, work placementsand volunteering roles available.

We are an inclusive employer and welcome applications from everyone whatever their sex; religion or belief; race; age; sexual orientation; gender identity or, whether they are pregnant or have recently been on maternity leave, married or are in a civil partnership; or, whether they are disabled.

Our values - Caring For Each Other, Working Together and Always Improving, show thatour commitment to equality is at the heart of everything we do.

If you want excellent career and training opportunities while living on the doorstep of some of Europe's most spectacular scenery,with all the benefits of a thriving and cosmopolitan city - look no further.

The ability to speak Welsh is desirable for this post; Welsh and/or English speakers are equally welcome to apply.

Job description

Job responsibilities

Incident Investigation

To support the Lead Patient Safety Incident Investigator to enable the delivery of an efficient and effective high quality service.

To work autonomously, leading on complex investigations where there has potentially been serious harm to patients and when a Never Event has been identified.

To undertake investigations and to complete an investigation report within the designated timescale reported to the NHS Wales Executive.

To participate in strategy meetings with Service Groups in order to identify/agree the scope and key lines of enquries for investigations.

To consult with Specialist Advisors as appointed by the Service Group, working with them to review timelines, process control maps and discuss the learning outcomes/recommendations related to the incident.

To request witness accounts from staff involved in incidents.

To review staff witness accounts and, where necessary, meet with staff to discuss the witness account, obtain further information and to clarify any outstanding issues.

To consider the impact that the incident and investigation may have on staff and ensure that staff are aware of how to obtain support.

To ensure that staff are supported during the process and that staff understand that the investigation is not about apportioning blame but is about learning and improving patient safety.

To develop a time line of events in relation to the incident.

To establish and review key appropriate Health Board policies, Standard Operating Procedures (SOPs) and any National guidance from professional bodies relevant to the incident.

To create a Process Control Map to include mapping out relevant policies and SOPs to establish and outline where practice met the relevant standard/guidance and where it did not.

To use other investigative tools as necessary.

To consider other causes that may have contributed to the incident.

To critically review and analyse highly complex and sensitive information to establish causes of a serious incident.

To write a robust report outlining the incident, the omissions/problems that occurred, the causes/contributory factors that impacted on the incident, identify lessons to be learned and to make recommendations for quality improvement.

To share the report with contributors and specialist advisors to ensure the incident investigation has been accurately reflected.

To share the report with Service Group Medical and Nurse Directors for approval prior to Executive Director for final agreement and sign off.

To ensure that throughout the investigation, all documents and relevant information is recorded within Datix Cymru.

To ensure that there is openness and transparency in all aspects of the investigation.

Management

To provide corporate quality assurance on the standard of submissions to the NHS Wales Executive and Welsh Government by monitoring the Patient Safety Incident Investigation email account to ensure that notification forms, early warning forms and outcome forms for Nationally Reportable Incidents from Service Groups are scrutinised and are of an acceptable standard prior to executive sign off and submission to the NHS Wales Executive.

To co-ordinate Patient Safety Incident and Never Event investigations (regardless of origin) ensuring that they are reported and scrutinised by the relevant Service Group ensuring that learning can be demonstrated and that investigations are concluded within appropriate time scales.

To represent in their absence the Lead Patient Safety Investigation in regular meetings with Service Groups to ensure they are fully engaged in investigations undertaken at Service Group level and are working towards investigation timescales set out at the start of each investigation.

To provide expert advice and support to Service Groups in relation to the reporting and investigation of incidents.

To provide support and mentorship to Service Groups conducting investigations.

To provide expert advice to the Health Board to ensure that learning from the investigation of incidents leads to improved patient safety.

To provide advice to Service Groups in relation to Being Open and the requirements for the Duty of Candour.

To review and analyse collated data from Datix Cymru relating to patient safety incidents; to identify themes and trends and escalate areas of concern accordingly.

To work with the Patient Safety Incident Support Officer to contribute information and data to Health Board dashboards as required.

To work with the Patient Safety Incident Support Officer to ensure that reports relating to serious incidents and Never Events are accurately provided to the Lead Patient Safety Investigator and the Assistant Head of Concerns Management for the Health Boards Quality and Safety Committee.

To ensure that the National Reporting and Learning System requirements and timescales are met.

To promote a culture of patient safety that focuses on high quality standards of care, preventing avoidable harm/avoidable death by using evidence-based best practice, identifying themes and learning lessons.

To work with all levels of staff to ensure that patient safety is a key Health Board priority.

To deputise for the Lead Patient Safety Incident Investigator as necessary; liaising with Executives and other senior Health Board staff, Service Group staff, Welsh Government staff and staff from other external bodies/agencies.

To work with Best Practice teams (Continence, Falls, Tissue Viability, Nutrition), Clinical Academic Teams, Organisational Development and Service Transformation Teams to develop and embed sustainable improvement.

To participate as necessary in audits linked to patient safety .

To collaborate with staff from other Health Boards in investigations as necessary.

Professional

To demonstrate knowledge of research and development in the field of patient safety and advise on how this can be applied in the Health Board.

To keep up to date with developments (nationally and locally) in relation to Serious Incidents.

To attend National Patient Safety forums.

To keep up to date with all elements of incident and serious incident modules in Datix Cymru

To ensure own continued professional development and support a culture of life-long learning.

Leadership

To demonstrate strong leadership in discussions and negotiations with Service Groups.

To demonstrate leadership and positive role modelling in respect of creating a patient safety culture.

To demonstrate the values of the Health Board; caring for each other, working together and always improving.

To recognise that, due to the distressing nature of some incidents, cases may impact on the post-holders wellbeing or that of other investigators and to guide staff as necessary to wellbeing services and other support.

To ensure that themes emerging from incident reporting/investigation contribute towards Health Board processes, policies and strategic planning.

Communication

To communicate regularly with the Lead Patient Safety Incident Investigator and colleagues in the Patient Safety Incident Investigation Team to ensure the team are aware of progress, issues and developments in investigations.

To communicate regularly with the Lead Patient Safety Investigator, escalating concerns and potential problems in relation to investigations and other patient safety issues.

To communicate with a wide range of staff and other stakeholder and to do so clearly in a language they understand.

To liaise with other staff within the Patient Feedback Team to support the Lead Patient Safety Incident Investigator in triangulating themes and trends.

Management, Leadership and Training

To demonstrate strong leadership in discussions and negotiations with Service Groups.

To demonstrate leadership and positive role modelling in respect of creating a patient safety culture.

To work with the Patient Safety Incident Support Officer to contribute information and data to Health Board dashboards as required.

To work with the Patient Safety Incident Support Officer to ensure that reports relating to serious incidents and Never Events are accurately provided to the Lead Patient Safety Investigator and the Assistant Head of Concerns Management for the Health Boards Quality and Safety Committee (including themes and lessons learned).

To demonstrate the values of the Health Board; caring for each other, working together and always improving.

To recognise that, due to the distressing nature of some incidents, cases may impact on the post-holders wellbeing or that of other investigators and to guide staff as necessary to wellbeing services and other support.

Digital and Information

To participate in strategy meetings with Service Groups in order to identify/agree the scope and key lines of enquires for investigations undertaken by the Patient Safety Incident Investigation Team.

To represent in their absence the Lead Patient Safety Investigation in regular meetings with Service Groups to ensure they are fully engaged in investigations undertaken at Service Group level and are working towards investigation timescales set out at the start of each investigation.

To share the report with contributors and specialist advisors to ensure the incident investigation has been accurately reflected.

To share the report with Service Group Medical and Nurse Directors for approval prior to Executive Director for final agreement and sign off.

Education and Training

To support the Lead Patient Safety Incident Investigator by contributing towards the development and updating of training packages.

To support and develop the capability of staff in incident investigation and improvement methodology by leading Incident Investigator Training sessions.

To ensure that themes from Nationally Reported Incidents are used to inform Health Board training priorities.

To support the Lead Patient Safety Incident Investigator by contributing towards the Patient Safety Team newsletter.

Person Specification

Experience

Essential

Extensive knowledge of patient safety methodology Experience of investigating complex cases.

Qualifications & Abilities

Essential

Educated to degree level or equivalent. Specialist knowledge and experience of statistical / analytical / epidemiological techniques and procedures, acquired through degree level or equivalent plus additional specialist knowledge acquired through post graduate diploma level or equivalent relevant experience Relevant post graduate diploma or equivalent qualification / experience in safety, clinical governance, risk field Considerable knowledge or Root Cause Analysis investigative processes Extensive knowledge of patient safety methodology Current working knowledge of Datix Cymru Experience of investigating complex cases. Ability to prioritise workload to work autonomously and to work effectively as part of a team. Able to maintain effective relationships and develop networks both internally and with external organisations to ensure effective governance Ability to travel within geographical area and to work flexibly. Ability to present complex issues clearly and concisely at all levels of the organisation, including to executive colleagues

Desirable

Welsh Speaker (Level 1) Experience of delivering staff training programmes.

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