Published August 2021.
We’re yet to decide this. The independent evaluation of the Early Adopter pilot programme, that will complete in Autumn this year, will inform decisions about what changes we will make to national policy on patient safety incident response and the associated frameworks. Should the results of the pilot support wider implementation of PSIRF, there are still various options for roll out which will be assessed based on what the evaluation of the pilot tells us.
The PSIRF pilot has included independent sector providers who deliver out of hours and urgent care services, and those who provide healthcare in prisons. This has allowed us to gain insight about how the PSIRF can be applied in these settings. One of the Early Adopters is working as a system bringing together acute, community, and primary care services. We are collating insight as part of the evaluation, and this will inform the implementation strategy (including how to support PSIRF implementation within the independent sector). Specifically, for primary care we are interested in exploring whether Primary Care Networks can support PSIRF implementation, as individual providers are unlikely to have enough resource and capacity if working in isolation.
HSIB continue to investigate maternity incidents that meet their criteria.
As part of the development of Patient Safety Incident Response Plans organisations consider risks and specific incident types across all the services they deliver and decide how these must be responded to.
The Patient Safety Team are also working with colleagues leading on the national maternity programme to understand how to support alignment with new ways of working under PSIRF and national maternity workstreams and expectations, particularly following the recommendations made by Ockenden report. This will be a key part of PSIRF Implementation Strategy Development.
We have three mental health providers included in the PSIRF pilot. The PSIRF does not change current requirements set by the Learning from Deaths framework. The Patient Safety Team are working with our mental health Early Adopters to understand how to utilise review and investigation processes most effectively. We are also exploring how system improvement plans can be used to avoid separate action plans being produced at the end of each review and/or investigation process, which can result in an unmanageable number of actions.
The PSIRF is much broader in scope compared to the Serious Incident Framework; instead of focussing on a small proportion of incidents deemed ‘serious’, PSIRF aims to support the development of systems and processes for incident response more broadly. Discussions between commissioners and providers (or among ICSs in the future) should be focused on how incidents are identified, recorded and responded to (on the basis of risk), and how the evidence of change and improvement is being measured as a result of the insight gained.
Commissioners are integral to the development of the PSIR Plan and should be involved in reviewing the plan on a regular basis. Under PSIRF commissioners are responsible for ensuring providers continuously assess and develop their systems and processes for incident response.
We are continuing to learn about the role of ICSs as structures develop. We expect ICSs will replace the commissioning functions; to support the development of PSIR Plan, monitor progress against the plan and ensure at a place and system level there is continuous assessment and development of systems and processes for incident response.
Yes, we’re currently looking at the best comms routes for coroners locally and nationally.
There are many things that can be put in place before PSIRF is finalised in the spring. You can consider reviewing how you include family and staff in your investigations to ensure an inclusive approach throughout; you can review your approach to investigation to ensure you are taking a systems approach; you can ensure that you are only using trained investigators who have dedicated time to lead investigations; and you can ensure you have the systems in place to encourage reporting and subsequent learning and improvement. These steps are covered in Part A of the current version of the PSIRF.
The NHS Patient Safety Strategy Update includes objectives which local systems can use to support PSIRF implementation planning and preparation. Specific objectives (based on those in the updated strategy document) were also circulated to Patient Safety Specialists.
We are working with our Early Adopters to revise our current templates and resources. We expect to provide you with:
- an updated Patient Safety Incident Response Framework, including a preparation guide
- an updated Patient Safety Incident Response Plan Template
- an updated Patient Safety Incident Investigation Report template (and associated tools/framework)
- Examples of Patient Safety Incident Response Plans
- Communication resources (slide deck, video)
The evaluation programme currently underway will also enable us to explore what type of support infrastructure would be beneficial.
It is important to ensure that the investigations are conducted by trained investigators with dedicated time to investigate, regardless of PSIRF.
Some of our Early Adopters have restructured their investigation teams to form ‘incident response’ teams to work under PSIRF. PSIRF is a significant shift in how we respond to and learn from patient safety incidents. It is important to consider how teams might need to be restructured to accommodate this new way of working rather than trying to work out how to encompass a new approach into existing processes.
The Patient Safety Incident Investigation standards outline the requirements for conducting investigations. It is important to note that these standards can be implemented prior to PSIRF ‘go live’ as they already represent good practice in investigation, although the standards will be updated prior to PSIRF roll-out.
You don’t have to wait until decisions are made about implementing PSIRF to ensure those involved in learning from patient safety incidents are trained in systems approaches, and some providers are already taking a systems approach to patient safety incident investigations.
For those wishing to refresh or to procure new training there is ongoing work across the system to help improve the standard and consistency of training related to learning from patient safety incidents. This work includes:
- The National Patient Safety Team are developing a procurement framework for training on learning from patient safety incidents. Importantly, the framework will include three types of training:
- two-day training courses in learning from patient safety incidents
- one day training course in the oversight of learning from patient safety incidents
- one day training course covering family and staff involvement alongside Duty of Candour
- The National Patient Safety Syllabus will contain some content related to patient safety incident investigation, human factors and systems thinking
- HSIB are developing training for investigators and for those overseeing investigation.
The PSIRF does not change any of the requirements relating to Duty of Candour. The intention of the Duty of Candour legislation is to ensure that providers are open and transparent with people who use services. It sets out some specific requirements providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. Duty of Candour does not specify which response type/method must be undertaken in response to an incident.
We are continuing to work with our Early Adopters to understand the impact of PSIRF on patients, families and carers. We have developed an information leaflet for families that we’ve provided to our Early Adopters to test and adapt. We are also about to commence an independent evaluation of the Early Adopter programme and the family perspective is a key part of the evaluation.
Currently we expect this to remain part of the NHS England and NHS Improvement regional team function. Work is underway to develop an understanding of the ICS role in supporting this function. Work is also underway to strengthen links with regional independent investigation teams and the National Patient Safety Team.
We will be evaluating the Early Adopter programme using an external contractor. If it is shown to have benefits and to support the kind of response to incidents that we wish to provide then it will be introduced more widely. We will however continue to evaluate its implementation and impact during any wider roll out.