New HSE investigative process

A first draft of a new HSE investigation process has now been developed, Cora McCaughan, Chair of the HSE Investigation Process Working Group (IPWG) told a recent  HRMF Forum.

A first draft of a new HSE investigation process has now been developed, Cora McCaughan, Chair of the HSE Investigation Process Working Group (IPWG) told a recent Healthcare Risk Managers Forum (HRMF), Educational and Networking Meeting.

Cora McCaughan, Chair of the HSE Investigation Process Working Group speaking at the Healthcare Risk Managers’ Forum
Cora McCaughan, Chair of the HSE Investigation Process Working Group speaking at the Healthcare Risk Managers’ Forum

The next step is for the working group to finalise the procedure based on feedback from a widespread consultation and engagement with staff and service users and from the feedback of a technical expert working group and a trade union reference group.

A pilot training programme for the delivery of this HSE Pilot Investigation Process is planned for the first quarter of 2011. The IPWG is collaborating with the School of Psychology at Trinity College Dublin for the development and evaluation of a creative, innovative five day training programme that will be highly practical and participative.

HSE staff, who are trained and experienced in the various existing HSE Policies which  have an element of investigation, and service users will be invited to participate in this investigation training.  Pairs of training participants (service user and HSE staff together) will then conduct investigations using the new procedure.

The experience of all involved including the investigation commissioner, staff and service users who participate in the investigations will be measured.  The findings of this pilot will inform the final recommendations of the IPWG to the HSE Senior Management team and will include a recommended HSE Investigation Process, and recommended training and support for its implementation.

HMI Vice President, Mr. Derek Greene and HMI Past President & Vice–President of the European Association of Hospital Managers, Mr. Gerry O’Dwyer, who discussed the development of collaboration between the HRMF and the HMI at the Forum
HMI Vice President, Mr. Derek Greene and HMI Past President & Vice–President of the European Association of Hospital Managers, Mr. Gerry O’Dwyer, who discussed the development of collaboration between the HRMF and the HMI at the Forum

Ms. McCaughan said that the purpose of the Investigation Process Working Group is to standardise, simplify and strengthen complaint/incident investigation processes in the HSE which will:

  • Enable look back review and clinical performance review to be conducted as part of an investigation where a requirement to do this is identified.
  • Dove-tail this simplified complaint / incident investigation process into the proactive risk management process and the learning and sharing / quality improvement process.

The working group established a Technical Reference Group with members who have a lead role in numerous HSE policies that have an element of investigation associated.  The policies include:

Prof. Brian Toft (OBE), who made a presentation on Isomorphic Learning to the Forum
Prof. Brian Toft (OBE), who made a presentation on Isomorphic Learning to the Forum
  • The HSE incident and serious incident management policy and procedures including the Incident Management Toolkit
  • Your Service Your Say Policy and Procedures
  • Good Faith Reporting Policy
  • Protected Disclosure Policy
  • Trust in Care Policy
  • Dignity at Work Policy
  • HSE Disciplinary Procedures
  • Health and Safety Investigations
  • Children First Investigations and the HIQA Guidelines for the investigations of incidents of death and serious harm to children in our care.
  • Draft Guidelines for the investigation of allegations of abuse against older persons
  • Investigations of radiation exposure incidents

The working group began consultation and engagement with staff and service users and a range other external stakeholders including the Department of Health and Children, HIQA, the Health and Safety Authority and the Forum of Health and Social Care Regulators. It also established a Trade Union Reference Group.

A series of nine consultation and engagement workshops took place across the HSE. Eight of these workshops included HSE employees and service users, and one of the workshops was for service users alone.  Over 320 staff and service users attended the workshops where they made a highly positive contribution to the HSE investigation process work. Workshop questionnaires and evaluations indicated that participants had a lot of views and experiences to offer to inform the investigation process work and that participants found the workshops to be helpful in ensuring that their views and experience inform this important work. Specifically, 83 per cent of participants were satisfied or very satisfied with the proposed investigation procedure and 73.4 per cent believed the procedure to be an improvement on existing procedures.

Some of those who attended the Forum  Back left to tight : Anne O’Neill, Clare O’Neill, JP Kehoe, Catherine Murray and Oonagh O’Grady Front left to right : Cora McCaughan, Professor Brian Toft, John McElhinney and Irene O’Byrne Maguire.
Some of those who attended the Forum Back left to tight : Anne O’Neill, Clare O’Neill, JP Kehoe, Catherine Murray and Oonagh O’Grady Front left to right : Cora McCaughan, Professor Brian Toft, John McElhinney and Irene O’Byrne Maguire.

Following widespread consultation with staff, service users, educators and regulators, the working group has now developed a first draft of the investigation process.

For more information about this project, contact Ms. Deirdre Coyne on deirdre.coyne1@hse.ie

Investigation Process Working Group Membership:
  • Project Sponsor:  Dr. Joe Devlin, Quality Clinical Care Directorate
  • Chair:  Cora McCaughan
  • Service User Rep.:  Cathriona Molloy, Patient Focus
  • Service User Rep.:  Rebecca O’Malley
  • Partnership Facilitator, Health Services National Partnership Forum: Seosamh Ó Maolalaí
  • Health Intelligence:  Mary Morrissey
  • Lead for Quality, Clinical Audit and Research:  Dr. Samantha Hughes
  • Area Manager, Consumer Affairs:  Debbie Keyes
  • HSE Advocacy Unit, QCCD:  Greg Price and Juanita Guidera
  • Human Resources:  Anna Killilea and Andrew Condon
  • Communications:  Fidelma Browne
  • QCCD:  Deirdre Coyne, Debbie Kavanagh
  • ISD: Dr. Anne Hogan
  • External Independent Expert Advisor:  Professor Brian Toft, Professor of Patient Safety at Coventry University; and Brighton University and Surrey University Medical Schools