Patient Safety Incident Response
A new era of safety learning in the NHS?
Written by Sian Williams, NHS Team Lead & Managing Consultant and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
We work with a network of amazing Interims, many of whom are true specialists in niche fields. The track record of one such Interim recently inspired me to dig deeper into his chosen specialty, namely patient safety incident responses, which is currently being overhauled. What at first appeared to be a dry, but obviously an important topic, turned into quite a gripping research journey, not in terms of past failings but in terms of forthcoming improvement initiatives. Here are some of my findings and thoughts.
Every day, millions of people are treated safely and successfully in the NHS, but tragically, things sometimes can go wrong. Healthcare is a people business, and with the very best intentions, people can make mistakes and more often than not, vulnerabilities within complex systems will have contributed to adverse outcomes. However, when patient safety incidents happen, it is important that lessons are learned to prevent the same safety incident from occurring again?
Improving safety is about reducing risk by optimising good practices and minimising mistakes. At the same time, it is also about making sure there is a renewed focus of learning from what goes well or what’s called safety II (which essentially is understanding work as done rather than work as imagined). The renewed systems approach to improving patient safety is two pronged:
- Firstly, strengthening (and replicating) practices and processes which lead to good outcomes and
- Secondly, engineering out the vulnerabilities in those processes which contribute to harm
Patient safety is integral to the NHS’ definition of quality in healthcare, alongside effectiveness and patient experience. It is what drives the NHS to want to be one of the safest healthcare systems and best learning environments in the world.
My reading showed that historically, the quality of local NHS investigations into serious patient safety has been inconsistent across different NHS organisations. The reasons for this are many and varied and different in each context, but key contributing factors include:
- Staff workloads,
- Lack of skilled investigators or training,
- A blame culture discouraging staff willingness to speak up.
Meanwhile, there is a perceived failure to apply learning from failure.
These existing shortcomings are being addressed by an NHSE/I initiative within an overall patient safety strategy, announced in 2019. This is an area that strikes me has the potential to require subject matter expertise combined with real-life experience, namely an Interim who has seen and done it before.
One particular area that could be boosted with short-term expertise is the patient Safety Incident Response Framework (PSIRF), a key element of the new strategy which is on track to be rolled out across all Integrated Care Systems (ICS) starting spring 2022.
The Need for A Patient Safety Strategy
Serious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances.
Annually about 20,000 investigations are initiated across England and Wales. Furthermore, NHS Resolution’s Annual Report and Accounts show that there were 11,682 new clinical negligence claims and reported incidents in 2019/20 (compared to 10,684 in 2018/19) and expenditure on clinical claims amounted to over £2.3 billion.
This is a huge cost to bear, so little wonder that patient safety is under constant scrutiny. Prompted by some high-profile failings there have been countless reports with solid recommendations. These have ushered in new ways of working and new systems, including the Healthcare Safety Investigations Branch (HSIB), set up in 2017 to investigate incidences national incidences that are referred to it. But the number of incidence stats reported routinely to the National Reporting and Learning System (NRLS) have continued on an upward trajectory. Perhaps some of this can be contributed to NHS performance being measured by the success or failure of achieving set targets. While targets are important these should never displace the primary goal of better care.
Enter the new NHS patient safety strategy which brings together a number of initiatives around safety and learning to prevent harm, including:
- A new safety and learning system to replace the National Reporting and Learning System (NRLS)
- A new system for investigating or reviewing patient safety incidents – the Patient Safety Incident Response Framework (PSIRF)
- Various improvement programmes (e.g., maternity and neonatal, medicines and mental health)
- Sector-specific issues (e.g., older people, learning disabilities).
At the heart of the strategy is the need to ‘significantly improve the way in which the NHS learns, treats staff and involves patients’. These initiatives are designed to save around 1,000 lives and £100m in care costs each year from 2023, with the potential to reduce claims provision by around £750m a year by 2025.
This patient safety strategy takes on board the findings from:
- A number of high-profile reports, including one by the Care Quality Commission (CQC) commissioned by NHSI
- The work of HSIB, especially in maternity investigations
- The findings from an extensive NHS-wide patient safety consultation held in 2018
All this input supports that NHS staff are not to blame – in the vast majority of cases, it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems. These are the issues that the new strategy seeks to address with the new patient incident response framework (PSIRF).
PSIRF – What is changing
The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots.
So, what’s changed? Fundamentally the framework is:
- Refocusing systems, processes, and crucially, behaviours to improve the quality of investigations and achieve a ‘learning from’ environment
- Broader in scope with a move away from a focus on current thresholds for serious incidents
- A Risk-Based approach giving recognition to the fact that while some incidents require a Patient Safety Incident Investigation (PSII), there are other proportionate responses such as case note reviews, ‘being open’ conversations, incident time mapping and audits.
- Moving to systems-based patient safety investigations using a range of investigative methodologies rather than the reliance on root cause analysis.
- Enabling timeframes to be agreed with those affected and not within pre-ordained time limits
- Mandating the development of a patient safety incident response plan (PSIRP) which then needs to be reviewed
every two years setting out how incidents will be identified and investigated. In other words, a continuously updated framework with learning at its core.
The PSIRF heralds a new era for the management of incidents in the NHS, with the objective of:
- Improving patient safety across the system
- Encouraging a culture of learning and safety improvement throughout the healthcare system
- Driving greater consistency in the quality of investigations.
After the COVID-19 pandemic ends, there will be a new normal in the NHS. Continuous improvement will drive this new normal.
To conclude, is your organisation ready for the significant changes and local collaboration that PSRIF demands to ensure the delivery of quality health services?
Or could you use the help of a Patient Safety Incident Response expert with experience of playing a key role in one of the early adopter pilot implementations? Get in touch if you do.
And finally, my thanks go to the Patient Safety Learning organisation for providing an excellent source of reference.
Sian Williams, NHS Team Lead & Managing Consultant
Health & Social Care Group
Health & Social Care Managing Consultant
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