An Investigation Report for Systems Learning: COVID-19 Outbreak Control Team Weston General Hospital

Bringing together a standardised data set (encompassing population health) across the system to better support analysis, understand trends, issues and emerging themes. Action should be taken to ensure that joined-up data streams are available which focus on the micro and macro levels with an accompanying narrative that better describes what is being presented.

Review Incident (Major and System Critical) guidance to ensure a single system is in use and a single line of accountability and joint governance is clear for the management of an Incident (Major or System Critical) when both EPRR and OCT are running in parallel including agreed timelines for closure.

A regional ‘tabletop’ exercise should be considered within the wider system for those other organisations that support in an Incident (Major or System Critical) in which protocols that bring EPRR and Outbreak Management together are tested ensuring clear understanding of joint system governance, decision making and accountability.

Ensure the process of clinical system leadership and decision-making is clear and the joint governance underpinning decisions provides clarity of accountability and responsibility.

Review the role of outward facing, coordinated communication (system, regional and national) to the Outbreak Management plan. Making explicit and recognising the intensity, complexity and multifaceted nature of briefing multiple stakeholders ensuring a single narrative when the context is continuing to rapidly change and evolve.

In light of the development of new clinical pathways and patient flow as a result of the temporary closure of Weston General Hospital, optimise system learning and transformation linked to quality focussed patient outcomes.