Hse Incident Management Framework 2020 Presentation

Welcome to the launch of the Incident Management
Framework (2020). The event will start shortly.
Should you have any questions or comments, please use

chat box and select all attendees when sending your
question / comments.
Should you lose connection or if your sound quality is poor,

you may wish to mute your computer audio and dial in by
phone.
Dial in details for the event are

01 5260058
Access Code: 137 396 9504#
Note: this session is being recorded

Message from the CEO
Format of Session
• Process undertaken to revise the IMF
• Lessons from practice
• Key changes in the 2020 version

Background to the revision
HSE Incident Management
Framework launched in 2018
Commitment to review after a

year to gain an understanding
of its use in practice and to
identify any areas where
additional clarity or guidance
may be required
Review Process
• Online questionnaires, meetings, workshops
and focus groups.
• Alignment with National Patient Safety
Strategy and revisions to the HSEs Open
Disclosure policy.
• Consultation with QPS advisors
• Sign off by HSE Safety and Quality Committee
and the EMT (Sept 2020).
Lessons from practice
Lesson 1 . Learning to talk about error before
it happens
To develop a culture of
safety we must first
create a culture of
psychological safety
where talking about
safety is a normal part of
the way we seek to
improve services.
Lesson 2. Before you start
When and when

not to use the
Incident
Management
Framework
Lesson 3: Lean In
Supporting service users and
families starts from get go and
continues.
Imagine
• You are that staff member

• You are that service
user/relevant person
How would you feel?

How would you want to be
responded to?
Lesson 4 – Trust is critical
“What I’ve found through
research is that trust is built in
very small moments…’ Trust is
the stacking and layering of
[these] small moments and
reciprocal vulnerability over
time. Trust and vulnerability
grow together, and to betray
one is to destroy both.”
Brené Browne
Lesson 5. Verifiable decision making
• The IMF at its core is a
decision making framework
• Decisions must be based on

evidence
• The evidence upon which

decisions are made should be
documented and verifiable
Lesson 6. It’s ok to decide that no further
review is required
Decisions must be
• Based on a preliminary
assessment and supported
by a reason
• Must be communicated
formally to service
user/relevant person and
staff
• Must be ratified by the QPS
or equivalent committee
Lesson 7. If you proceed to further review, do
so fairly
Not to do so risks
• Perception of a blame culture
• Loss of staff and service user

confidence – not just in relation to
this case
• Collapse of the review process

Lesson 8. The blue thread rule
Data
Recommendations should Analysis
flow from the data

gathered, its analysis, the Findings
findings and the factors that Contrib

Factors
contributed to them.
Recs
Lesson 9. Recommendations versus Learning
Recommendations are specific to

the context in which the incident
occurred.
Learning is something that other

areas/services may consider as
applying to them.
Reports may identify both.

Lesson 10. Keep reports simple and
accessible
• Long complex reports are
often counter- productive.
• Though your report will be

based on the analysis of a lot
of evidence it does not all
need to be included in the
report.
• Remember your audiences

Lesson 11. Make the change
Having identified what needs to

change to reduce the risk of
recurrence – Make the change!
Link actions where possible into

existing improvement planning
Lesson 12. Supporting Practice
Key Changes
• The Incident Management Framework (IMF)
• The IMF Guidance
• Documents supporting the IMF and Guidance

Key areas of change IMF
• Definitions - aligned with related legislative and
policy changes
• Policy statement - more explicit links made to the
Open Disclosure Policy
• Roles and Responsibilities - more explicit reference to
the role of the SAO and LAO
• Governance arrangements - Reference to the
availability of the IMF audit tool for self-assessment of
compliance
• Service User Liaison Person - now changed to
Designated Support Person (in line with PS Bill)
• Term Key Causal Factors - to changed to Findings
• Comprehensive Review – now one approach
• Requirements for management of Multi- Incident and
Cross Service incidents have also been revised
Key areas of change IMF Guidance
Definitions - aligned with related legislative and
policy changes
Creating a Just Culture – New Section
This section replaces the Incident Decision Tree
Guidance
SIMT – role in oversight of all Cat 1 incidents and on
notification of a new Cat 1 incident
Preliminary Assessment Form - This form has been
amended based on feedback
Approaches to Incident Review - Comprehensive
approach revised
Systems Analysis Guidance - incorporated into
overall guidance. A number of tools to support
analysis have also been included.
Developing Recommendations – rewritten based on
the output of a group convened to review the
process of developing recommendations
Retention of Records relating to an incident review
- NEW Section
Other areas of change
All supporting documents and guidance on website reviewed in
the context of IMF and Guidance 2020
Service User Info Leaflet – this now includes SU consents for

reviewers access to the healthcare record, participation in the
review process, inclusion of the review report on NIMS and sharing
of lessons learnt with other services.
Staff Info Leaflet – this rather than just relating to Systems Analysis
has been reframed in the context of incident review
PAF form – amended per feedback and revisions to the process
Application for expert nomination from the Forum – aligned to

new requirements of review process e.g. reference to Review
Panel and Review Team removed
NOTE: Access supporting documentation from

https://www.hse.ie/eng/about/qavd/incident-management/ rather than
rely on saved versions which may be out of date
Conclusion
Thank you all for your attendance today and to the many of
you who have contributed to the IMF 2020.
Hard copies of the documents and leaflets have been

delivered to each HG/CHO/National Services for onward
distribution.
Please visit the HSE’s Incident Management Webpage for
more resources.
https://www.hse.ie/eng/about/qavd/incident-management/

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Welcome to the launch of the Incident Management

Framework (2020). The event will start shortly.

Should you have any questions or comments, please use

Should you lose connection or if your sound quality is poor,

Dial in details for the event are

Note: this session is being recorded

• Lessons from practice

• Key changes in the 2020 version

Commitment to review after a

When and when

• You are that staff member

How would you feel?

• Decisions must be based on

• The evidence upon which

• Perception of a blame culture

• Loss of staff and service user

• Collapse of the review process

Recommendations should Analysis

flow from the data

findings and the factors that Contrib

Recommendations are specific to

Learning is something that other

Reports may identify both.

• Though your report will be

• Remember your audiences

Having identified what needs to

Link actions where possible into

• The IMF Guidance

• Documents supporting the IMF and Guidance

Service User Info Leaflet – this now includes SU consents for

PAF form – amended per feedback and revisions to the process

Application for expert nomination from the Forum – aligned to

NOTE: Access supporting documentation from

Hard copies of the documents and leaflets have been

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