Critical Incident Analysis – Experiences Shared Tracy Reed Education Facilitator for End of Life Care Essex Partnership University NHS Foundation Trust Gill Robertson Lead Nurse for Palliative and end of life care Princess Alexandra Hospital Written with support of John Zeppetella, Consultant, St Clare Hospice 13th July 2017

When they started Joint CQUIN in 2014/15 - West Essex Clinical Commissioning Group Commissioning For Quality and Innovation THE AIM: The focus was the continued education and improvement in quality of end of life care A Critical Incident Analysis meeting for healthcare professionals based in the Hospice, Community or Hospital to meet and reflect on areas of practice that proved difficult or particularly demanding and to share good practice Apprehension around the feeling of vulnerability but this soon subsided to build on our partnership working.

CIA meetings 7 meetings in 2014/15 12 meetings in 2015/16 (included 6 hospital based meeting as CQUIN) 5 meetings in 2016/17 Here we need to get across the point that we were all apprehensive when they started but we soon built trust and saw the value of these meetings as a learning environment and staff wanted to attend and those who did were very engaged to attend again.

Who is involved and Who Attends - Where meetings are held - How – What is involved - Who is involved and Who Attends - Where meetings are held - How – WHAT IS INVOLVED: The meeting is attended by members of the multi-disciplinary team including, doctors, nurses, allied health professionals and anyone else who is relevant to the incident. It is a forum to identify and discuss in a safe environment and reflect on clinical incidents good or poor care. It provides productive learning and influences future service provision. WHO IS INVOLVED AND WHO ATTENDS: St Clare Hospice including consultant, Princess Alexandra Hospital including palliative and end of life care lead, SEPT now EPUT including education facilitator for end of life care. Clinical representation from each organisation and any other person relevant to patient care including GP/Social worker/mental health team/ambulance service/CCG representation. WHERE MEETINGS ARE HELD The site of the meeting is rotated between providers. The chair role is rotated. It has proved difficult on occasions to get everyone involved with incidents able to attend. Feedback and learning on occasions was done through feedback. A template is used to provide the information in a reflective way. This includes: HOW Description of incident Background information Influencing factors Issues raised for the individual Reflection Action Plans

Themes of meetings Advanced care Planning Ethical Issues Ambulance Transfers Care Co-ordination Carer support CHC funding Communication Diagnosing Dying Ethical Issues Lack of Information Medication At Home Non-Cancer patients Out of Hours Care Supporting colleagues Symptom control The meetings identified many themes and helped us to recognise some common themes for future training.

Subsequent Meetings Issues Ceilings of care Do Not Attempt Cardio-Pulmonary Resuscitation -DNACPR Preferred Place of Death - PPD Patients in residential and nursing care at end of life Patients with dementia at end of life Patients with learning disabilities at end of life The main issues identified were around patients having mixed messages, not having a clear plan of care or recognition of death and dying. When more than one service or care provider involved there are issues about shared documentation, information around future care and often the community felt the hospital was doing it and the hospital felt the community should do it. End of life care is all our business.

Advantages Shared learning for all those who attend and especially those who have been involved. Better understanding of services and recognition of barriers with clear actions to learn from. Improved patient and carer outcomes. Recognition of services and partnership working. Staff who attended saw this as a valuable shared learning environment and felt safe to show their emotions and be honest with themselves and others.

Feedback “I think the value of the meetings is evident in how we are working and how the meeting has grown. Even when we get it wrong or good practice it is very positive to reflect and see others perspectives. It creates a real climate for evidence based practice for services and partnership working and has only been positive to patient’s safety and care.” “For me it was a real learning and sharing environment. I felt safe to expose my vulnerability and gained confidence to be truthful to the group and myself. I feel the learning and experience has been invaluable and think it is a positive way to develop and learn, I would have no concerns about attending again. ” Feedback has been extremely positive and proved a constructive approach to resolve, learn and work together. “I almost feel like I would like to write a paper on how the group has worked and what potentially has grown as a result of these meetings. Not just in shared learning, but service delivery, development and individuals confidence to challenge and question in the best interest of the people we are caring for.”

Thanks for listening