PSIRF Webinar Recap – PSIRF Learning Response Tools

[Webinar Recap] PSIRF Learning Response Tools – Integrating After Action Reviews to enhance learning and safety

PSIRF is coming in and replacing the previous SIF (serious incident framework), and organisations must be compliant by October 2023, but how much do you know about the new framework and how can it work in practice within your organisation?

In a recent webinar we hosted in partnership with HSJ, ‘PSIRF Learning Response Tools – Integrating After Action Reviews to promote learning and safety’, four experts discussed PSIRF and After Action Reviews (AAR) as well as taking a systems-based approach to learning from incidents.

The panellists included:

• Tracey Herlihey – Head of Patient Safety Incident Response Policy, NHS England
• Judy Walker – After Action Review Trainer and Conductor, iTS Leadership
• Lauren Morgan – Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford
• Molly Kent, Patient Safety Specialist, Radar Healthcare

This blog explores four main themes from this PSIRF webinar and walks you through the main points the panellists raised.

Scroll 👇 for the takeaways!

PSIRF webinar takeaways

1 – Shifting the mindset in everyday work

During the workshop, there was a lengthy discussion about the need to change the culture and mindsets to emphasise the value of systems and the tools available to help us in everyday work.

The consensus was that more time than a single meeting is needed to develop recommendations that deliver the systemic change required to effect change in daily work.

“Shifting culture towards the importance of systems, and the tools there to help us pick a part that everyday work, understand that everyday work and make recommendations that are then going to make sense in the context of that everyday work and make actual change, not just learning, change in our everyday. That’s when it’ll deliver impact for patients.”

– Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

“We have these methods, and they’re there to gather insight and respond to a patient safety incident, and that’s new learning. We don’t want to keep repeating the same thing over and over again. But also, you know, making sure that we’re actually making change happen in our day-to-day work as well.”

– Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England

2 – Working together on quality improvement and patient safety

Lauren Morgan was asked if incidents should be gathered by the patient safety team and the improvement step, or “actions,” should be left to the quality improvement team.

Lauren mentioned that recommendations are typically made by the person conducting the investigation and then passed on to the teams to develop actions. Then, multiple actions could result from a single recommendation to the team and system in question.

Lauren was quick to point out that “it works well when it works well,” but that it doesn’t work in every situation, and that structurally, the separation within hospitals isn’t necessary, and that working closer together between those teams would be extremely beneficial because many of the skills are transferable.

“If I think about many of the Trusts that I work within, quality improvement sits in a different building, in a different department, under a different line management from safety. That’s not helpful. We should be working together so that those teams are engaged from the start. They have many of the same skills so that actually that this is all done in the round, it makes sense. So I think much closer working between those teams to be really helpful.”

– Lauren Morgan, Human Factors Lecturer, Quality, Reliability, Safety and Teamwork Unit, Patient Safety Academy, University of Oxford

3 – Data-driven AARs (After Action Reviews) are key

The need for technology providers to supply a flexible solution for PSIRF so that different responses can be triggered depending on the event was a key topic during the webinar, as was how the learnings from these could be effectively rolled-out at scale across an entire NHS Trust or Integrated Care Board (ICB).

This, along with a long-term technology partner, feedback loops, and training, were all important topics covered during the webinar.

Molly spoke about Radar Healthcare’s recent workshop with NHS partners about PSIRF readiness and preparedness; you can read more about the workshop here. There was discussion about the need for feedback loops to be integrated in a live dynamic way in order for staff to see the value in recording data and learning in an agile manner.

Because the PSIRF toolkit involves so much documentation, document management that links to action plans and notices within Radar Healthcare eliminates the need for staff to remember to update and implement new policies; instead, the system will automatically trigger reminders. This means that organisations can check in, sense check where they’re at, and have a very fluid plan that allows them to achieve readiness by October 2023.

“PSIRF isn’t an investigation tool that’s prescribed, instead it’s advocating a coordinated and data driven approach and also embeds patient safety incident response within that wider system of improvement,”

– Molly Kent, Patient Safety Specialist at Radar Healthcare

4 – Buy-in from senior leaders is essential

Judy Walker, After Action Review Trainer and Conductor from iTS Leadership, spoke about after action reviews, their origins, and how this new response method in the NHS will change things for the better.

A key challenge for the NHS in effectively using a response tool like after action reviews, is the time required for staff to review patient safety incidents, as well as the buy-in required from senior leaders. For after action reviews to work effectively, there needs to be a culture where the senior leaders are bought in as after action reviews allow the hierarchy to be flattened and removes the blame, so that multi-professional teams can “learn from today to do it better tomorrow.”

“We must have the senior leaders, senior clinicians, and culture leaders completely on board with after action review because it devolves power down the chain of command.”

– Judy Walker, After Action Review Trainer and Conductor, iTS Leadership

Lauren agreed on this point and was eager to ensure that those involved in testing these methodologies understand from the start that the organisation is learning so that people don’t attend reviews with high expectations and then sign out from it forever.

 Summary

The session concluded with a question to the panellists from one of the attendees about staff reluctance to be open and honest due to fear of litigation and referral to professional and registration bodies. This raised an important question and challenge for organisations to provide support for staff who have dealt with an incident, which is why PSIRF is important in bringing about change and ensuring that there is support for both staff and patients.

The benefit of Radar Healthcare is that any incident or event can be captured and a plan developed from it that provides prompts to the appropriate people to ensure that support is provided throughout the investigation process. Find out more about our incident and events module here.

 Are you interested in joining our PSIRF workshops?

We’ll be doing more sessions like this in the future – if you’d like to be a part of our PSIRF workshops; you can contact our Patient Safety Specialist Molly Kent at molly.kent@radarhealthcare.com.

 See how Radar Healthcare can help you get PSIRF ready

Start your PSIRF journey

You may also be interested in our PSIRF podcast

In an episode of our podcast, our Chief Product Officer Mark Fewster had an insightful discussion with Helen Hughes, the Chief Executive of Patient Safety Learning. They delved into the details of NHS England’s Patient Safety Incident Response Framework. Tune in to discover how this framework is set to foster an open and just culture within the healthcare system. Mark and Helen also shed light on what we can anticipate during and after the transition, emphasising the crucial role of the implementation process in ensuring the success of PSIRF.