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PSIRF - changing how the NHS responds to patient safety incidents for learning and improvement

01 December 2022

Tags:

  • Patient Safety

Published in August 2022, the Patient Safety Incident Response Framework is a vital part of the NHS Patient Safety Strategy, which aims to continually improve and build on the foundations of a safer culture and safer systems.

The PSIRF replaces the Serious Incident Framework (SIF) (2015), however, it is important to note that it removes the ‘Serious Incidents’ classification and instead promotes a proportionate approach to responding to patient safety incidents. Simply, it is not a different way of describing its predecessor as it changes how the NHS responds to patient safety incidents for learning and improvement. Organisations are expected to transition within the next 12 months, by Autumn 2023.

Listen to our PSIRF special episode of What the HealthTech? with Helen Hughes, Chief Executive at Patient Safety Learning.

What is the PSIRF?

The PSIRF advocates an encompassing, data-driven approach to responding to incidents in primary and secondary care.

The framework moves away from defining a serious incident and now focuses on patient safety incidents, hoping to embed patient safety incident responses within the wider improvement culture. It isn’t an investigation framework like the SIF, instead it:

  • Prioritises compassion and engagement with people involved in patient safety incidents through a data-driven approach
  • Focuses on improvement in responding to patient safety incidents including shifting cultures to a wider systematic patient safety management

Aidan Fowler, National Director of Patient Safety, NHS England – “The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen – including the factors which contribute to them.”

Testing the Patient Safety Incident Response Framework

Between March 2020 and June 2022, the NHS worked with a small number of early adopters to pilot the framework in their organisations by creating Patient Safety Incident Response Plans (PSIRP).

A few examples of early adopters:

  • North Bristol NHS Foundation Trust
  • East Lancashire hospitals NHS Trust
  • Leeds Teaching Hospitals NHS Trust
  • Cornwall Partnership NHS Foundation Trust
  • Care UK (Independent provider of healthcare in prisons)

Many of the early adopters talk about how implementing PSIRF has made a huge, positive difference to learning from patient safety incidents.

“Rather than just picking out actions and writing them down on an investigation report never to be seen again, they are actually now focusing on improvement work, meeting up with quality improvement to get those improvements embedded and sustained in practice.” – Lisa Falconer, Head of Clinical Quality and Patient Safety, NHS Derby and Derbyshire ICB.

“This isn’t something that one person does, this is a team approach, this is a whole organisation approach, trying to engage a better culture, a sense of safety, a sense of being able to talk openly around when incidents happen.” – Lucy Winstanley, Head of Patient Safety and Quality, West Suffolk NHS Foundation Trust.

For more from the early adopters, take a look at the NHS website.

Which organisations need to be PSIRF compliant?

The PSIRF is mandatory for any services under the NHS Standard Contract. This includes acute, ambulance, mental health, community healthcare, maternity, and specialised services.

Secondary care providers that aren’t NHS Trusts are expected to use the PSIRF but may not need to complete the entire analysis for patient safety incident response planning. Instead, processes that encourage employee and stakeholder engagement will be launched.

Primary care services are not required to implement the PSIRF with it being optional instead. If they choose to, they should work with their integrated care board (ICB).

The four aims of PSIRF and how Radar Healthcare can help?

At Radar Healthcare, we can work alongside you to support your implementation against the main four aims of the framework:

Aim 1 – Compassionate engagement and involvement of those affected by patient safety claims

Learning from a patient safety incident can only happen if there are processes put in place to support the compassionate engagement and involvement of those affected, including patients, their families, and staff.

This means creating safe spaces and opportunities for discussion, understanding, and for asking questions that all parties may have in relation to the incident.

When a patient safety incident investigation (PSII) occurs, patients, their families, and staff should be engaged in a meaningful way as much as they want to be.

“First of we involve the patient, their families, and the staff in a way we didn’t use to. Although we did involve people it was often quite distant, we would ask for a statement and account of events. Patients and relatives probably didn’t get to hear about the investigation until after it was completed and approved. Whereas now we involve them right from the start and I’ve seen a real difference when we talk to the staff.” –  Megan Pontin, Patient Safety Incident Investigator, West Suffolk NHS Foundation Trust

Organisations and Trusts must have policies and guidance on hand to assist in these new processes, and special considerations must be allowed for those affected.

Radar Healthcare is designed to be flexible so you can configure the right processes with your patients at the centre. With the right workflows, it’s straightforward to include ongoing actions and feedback as part of your investigation while involving the patient, their families and your staff.

Aim 2 – Application of a range of system-based approaches to learning from patient safety incidents

The PSIRF will be encouraging the use of system-based approaches to patient safety incidents, instead of more linear methods of identification.

Organisations will be asked to use the national learning response tools and guides to understand and uncover contributing factors to a patient safety incident, or incidents, to drive improvements.

Those who lead the patient safety incident responses and those involved in the learning and improvement from these responses will need specific knowledge and experience, with the details of this stated in official standards.

Flexible for all learning response methods such as After Action Reviews, our system ensures you can capture all the relevant information to learn from. Radar Healthcare ensures that if an incident is logged, all the associated requirements, e.g., notifications or mandatory forms, are triggered so nothing gets missed, creating standardised behaviours. Fully integrated action plans ensure any issues of poor performance are quickly identified, managed, and tracked. You can also easily see areas where the most learning response methods are taking place so it’s easy to spot if there’s a particular ward having successes to share, or issues which might need to be reviewed.

Read more about our incident management module and how this can help here. You can also learn more about After Action Reviews by listening to our What the HealthTech? podcast episode with AAR expert Judy Walker from ITS Leadership.

Aim 3 – Considered and proportionate responses to patient safety incidents

The goal of the PSIRF is to maximise improvement, not to reach a particular threshold of patient safety incident responses. Each organisation has a finite number of resources, and they must use those resources in a way that benefits its approach to patient safety incidents.

Some incidents like Never Events and deaths require a PSII to understand the actions behind that incident and where improvements and learnings can be made. Similarly, certain incidents need to follow specific reporting and reviewing processes.

The PSIRF aims to put accountability and responsibility back into the hands of the organisations. If an organisation or Trust and its ICB are satisfied with the response to an incident, it will be acceptable to forego further action.

No two incidents are the same, and neither should the technology treat them as such. Radar Healthcare allows you to create, evolve, and adapt the right workflows for the patient and learning response method used in the incident to achieve the best possible outcomes. Review action and service improvement plans at a local or organisational level to spot trends, best practice, and learnings, which in turn, leads to preventative action planning and continual service improvements.

Aim 4 – Supportive oversight focused on strengthening response system functioning and improvement

Organisations must work collaboratively, understanding their shared aims of the PSIRF. An effective governance structure is expected, with ICBs required to facilitate that collaboration at both place and system levels.

The PSIRF also expects ICBs and other regulators to understand and evaluate the effectiveness of NHS providers’ response processes. The leaders of the providers are accountable for the quality of learning responses, not the providers themselves. However, providers should be open with the information relating to patient safety incidents and incident responses, as well as support the continuous development of the framework. More information about this is available inOversight roles and responsibilities specification’.

Radar Healthcare helps you create a culture of continuous improvement and organisational learning through data and analytics while sharing best practice and trends right across your organisation.

Our system gives you an insight into what can be improved, streamlining the required processes to achieve this. For example, if a patient has a fall, you are able to automatically send the right actions to the correct team members, ensuring the correct procedure is taking place and supporting continual improvement.

You can read more about our action and improvement plans, and how they can help you here.

Patient Safety Incident Investigation (PSII)

As part of the PSIRF, the PSIIs are carried out to improve systems. They involve investigating patient safety incidents to pinpoint both how and why they happen.

Data collection and analysis play a large part to help identify underlying system-based causes. Once identified, improvement plans can be put in place to address these issues and therefore help improve patient safety in the National Health Service.

The NHS provides tools and methods for PSII including incident mapping worksheets and contributing factors classification.

How technology plays a part

Having the right systems in place is a huge part of improving patient safety because quality data and analytics are the key to learning how to avoid incidents in the future.

Furthermore, the PSIRF aims to support NHS workers in developing and maintaining effective patient safety incident response and Radar Healthcare is on hand to ease their transition into a more cohesive culture.

Radar Healthcare is an integrated risk management system built with patient safety at the forefront. LFPSE compliant and packed with AI (which means you can start to spot trends and prevent incidents before they happen), the software helps you accurately log incidents, put in place action and improvement plans, and report on improvements made – all while creating a culture of true organisational learning. We’re here to help you to make a difference.

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