↓ Grade incident ↓ Notify commissioning body within two working days ↓ Incident reported on Serious Incident Reporting and Learning Framework within two working days ↓ Consult commissioner as necessary over grading ↓ The Company to establish appropriate investigation ↓ Undertake investigation communicating with relevant local health bodies, patient and carers if applicable. ↓ Develop action plan ↓ Submit incident investigation report to commissioner* ↓ ↓ Implement action plan → Commissioner closes incident ↓ Share lessons learned if appropriate ↓ Review actions taken See below for the Company’s grading/threshold charts of serious incident levels, their impacts/consequences and root cause analysis model we will use to continuously improve the overall quality of service. Serious incident grading chart Incident Example Incidents Investigation Timeframe Grade Grade and action 1 Avoidable or unexpected Investigation 1: The Company to death. submit initial report Concise root analysis (RCA) for both within two working Healthcare associated No Harm and Low Harm and/or where the days. infections. circumstances are very similar to other previous incidents. The Company will Adult safeguarding submit completed incidents (see the A concise RSA will enable the Company to investigation within Company’s Safeguarding ascertain whether unique factors exist, thus 45 working days. Policy for more focusing resources on implementing service information). improvement. Investigation Level 2:
↓ Grade incident ↓ Notify commissioning body within two working days ↓ Incident reported on Serious Incident Reporting and Learning Framework within two working days ↓ Consult commissioner as necessary over grading ↓ The Company to establish appropriate investigation ↓ Undertake investigation communicating with relevant local health bodies, patient and carers if applicable. ↓ Develop action plan ↓ Submit incident investigation report to commissioner* ↓ ↓ Implement action plan → Commissioner closes incident ↓ Share lessons learned if appropriate ↓ Review actions taken See below for the Company’s grading/threshold charts of serious incident levels, their impacts/consequences and root cause analysis model we will use to continuously improve the overall quality of service. Serious incident grading chart Incident Grade Example Incidents Investigation Grade and action Timeframe 1 Avoidable or unexpected death. Healthcare associated infections. Adult safeguarding incidents (see the Company’s Safeguarding Policy for more information). Investigation 1: Concise root analysis (RCA) for both No Harm and Low Harm and/or where the circumstances are very similar to other previous incidents. A concise RSA will enable the Company to ascertain whether unique factors exist, thus focusing resources on implementing service improvement. Investigation Level 2: The Company to submit initial report within two working days. The Company will submit completed investigation within 45 working days.
Serious_Incidents_Policy%20Final.docx