1. Safety Measuring & Monitoring Learning from Past Harms Peter Weller Director of Quality and Governance 12 th February 2015

3. What did we do to understand our history? Review of 2 years – Reconciliation of learning Organisational aggregation & systematic analysis by theme, area, location, Individual Third party reports Claims and pre-action MAPSAF & Cultural Assessments Complaints & PALS Inquests External Reviews Safety leadership walk rounds Practice Governance reviews Contract monitoring issues including CQUINS Organisation Internal Feedback – Listening to staff Regulatory Outcomes Incidents SI’s Patient Safety Programme Quality Improvement Strategy Patient Experience Strategy Values & Behaviours OD Strategy Nursing & Midwifery Strategy Leadership development & Improvement Programme Moving beyond incident reports was a necessity Health Economy measures (Keogh) Patient perspective is essential