1455 ed marsden slides 050315
TRANSCRIPT
IMPROVEMENT THROUGH INVESTIGATION
The role of independent investigations, including parallel investigations
Ed Marsden, managing partner, Verita
National Healthcare Conference, Dublin 2015
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Aim
• What are the triggers?
• What are the benefits and risks
• What are the implications of parallel investigations – particularly focusing on an investigation being carried out by the police?
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What is an independent investigation?
• Evidence based review with details gathered from a wide range of sources
• External, impartial investigators
• Objective findings
• Lack of pressure from commissioners
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What are the triggers
• Severity of the outcome
• The law
• Degree of public interest
• Capacity and capability of an organisation to investigate itself
• Views of families or the public
• Likely scrutiny of outcome
• An organisation’s own policy
• It’s the right thing to do
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“The problem with free elections is that you can’t predict the outcome.”
What are the benefits and risks?
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Benefits
• A thorough and persuasive investigation that sheds light on a complex matter
• A full and truthful exposition of facts
• Victims, relatives and staff feel engaged and heard
• A powerful set of recommendations to support improvement and change
• An independent account that can be published
• Interested parties given a truthful and unbiased account
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• The investigation report doesn’t convince
• The investigation is procedurally unsound
• The outcome comes as a surprise
Risks
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Parallel investigations
• There is nothing in UK law that says investigating a crime comes before investigating a patient safety incident
• An MoU signed in 2006 gives healthcare providers the framework to ensure effective working of parallel investigations
• Two good reasons for running parallel investigations:• Patient safety• Relatives and families
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Summary
• Independent investigations are likely to gather even more traction in organisations working to the open disclosure policy.
• Every organisation should know when and how to commission an independent investigation.
• Seek advice before commissioning.
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Action
Are you clear about the circumstances that
would trigger such an investigation?
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Partnership with British Medical Journal (BMJ)
• Aimed at delivering patient safety programmes
• Based on our investigative experience and BMJ's quality improvement programme (QIP)
• Consultancy & online tools to guide interventions
• Currently working with a UK hospital on oxygen therapy & falls
IMPROVEMENT THROUGH INVESTIGATION
The role of independent investigations, including parallel investigations
www.verita.net/Dublin-conference