The Patient Safety Incident Response Framework (PSIRF), which replaces the Serious Incident Framework (SIF), is a significant change to how the NHS responds to incidents. NHS organisations are expected to complete their transition to this framework by Autumn 2023, with the adoption of PSIRF mandatory for all service providers under the NHS Standard Contract.
Here, we consider the change in approach that all acute, ambulance, mental health and community healthcare providers will need to be familiar with, and the anticipated benefits.
Change in approach
The PSIRF (which can be found here, together with supporting guidance) is a system-based approach to learning. It is the new approach by the NHS to developing and maintaining effective systems and processes, when incidents occur. Central to the process is understanding that patient safety incidents do not arise from a single action but as a result of many components. These components include people, technology, resources, the environment and their interaction.
Under PSIRF, there is no distinction between ‘patient safety incidents’ and ‘serious incidents’. Essentially, the threshold for classification of an incident has been lowered.
A proportionate approach is promoted, given the resources available to NHS organisations. However, a focus on learning and improvement is expected, with wider stakeholder engagement than has previously been the case.
The framework is not prescriptive. Instead, the aims (according to NHS England) of PSIRF include that it:
- “Advocates a co-ordinated and data-driven approach to patient safety incident response that prioritises compassionate engagement with those affected by patient safety incidents”.
- “Embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management”.
Taking a practical approach, under this new framework, if an NHS organisation wanted to examine the impact of a shortage of theatre availability at particular points in the week, then one review is undertaken, with all affected patients being considered. Previously, under the SIF, the review would not have been undertaken unless there was a serious incident reported.
Engagement of all those affected by the incident is central to the process. For patients, by involving them from the beginning of the investigation, the investigation will cover what matters most to them.
Whilst the focus remains the ‘incident’, there is scope, via the above, for complaint issues to be addressed early, as part of involving patients and families.
Patient Safety Incident Response Plan (PSIRP)
NHS organisations are required to prepare a PSIRP, setting out how the organisation intends to respond to patient safety incidents, in line with the national template. The desire is that the plan is tailored to local context and the organisation who has created the plan. The early adopter programme has assisted in developing this ongoing and evolving system of improvement.
The framework sets out the following methods, for NHS organisations to choose, so as to facilitate learning:
In-depth review of a single patient safety incident or a cluster of incidents. They are undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
The aim of a PSII is to provide a clear explanation of how an organisation’s systems and processes contributed to a patient safety incident. They are mandatory for certain patient safety incidents such as never events, deaths under ‘learning from deaths’, and Mental Health Act cases. Otherwise, it is for the organisation to decide whether they are required.
There is a PSII report template that should, according to NHS England, be adopted unamended. NHS England have confirmed that they will continue to review and evaluate the design of the template, and encourage feedback from those using the template.
An open discussion, for patient safety incidents that occurred in the past and/or where staff recollection is poor, to agree the key contributory factors and system gaps.
Where staff ‘swarm’ to the site soon after the incident to gather information on what and why something has happened and decide what needs to be done to reduce risk of a repeat event.
Facilitated discussions following an activity or event that has been particularly successful or unsuccessful. To capture learning and promote success for the future.
NHS organisations are also encouraged to conduct thematic reviews of past learning responses and conduct horizon scanning to identify or predict issues regardless of whether or not an incident has occurred.
We consider the introduction of PSIRF, which, we believe, accords with a just and learning culture, should be welcomed. There is the potential, via PSIRF, not only to ensure patients receive safer care, but also to have a positive impact for healthcare professionals.
PSIRF will significantly impact the day to day work of governance, legal services and patient safety teams within NHS organisations. The implementation will of course be resource intensive whilst teams get up to speed and put this framework in place.
However, the intended benefits of the new approach are considerable. If the framework is implemented effectively, incidents should be less likely to re-occur. Further, if they do re-occur, then the level of harm suffered should be less significant. Incidents being anticipated via previous learning.
A well run NHS organisation, with a robust patient safety team, has the opportunity to thrive under the PSIRF process. Reason being it takes the investigation and subsequent sharing of learning much closer in time to the incident. This should yield meaningful improvement.
Unlike SIF, where issues are isolated at the end, PSIRF allows for early identification and communication across the NHS organisation by way of interim update.
If implemented well, PSIRF, which excludes “activities that apportion blame or determine culpability”, should support an environment where staff know they are supported and are empowered to learn, instead of the potential to feel blamed. Patient safety events are upsetting for healthcare professionals and they need looking after.
PSIRF also has the benefit of giving greater local flexibility. This should allow NHS organisations to shape the approach to the investigation in a way that staff feel able and want to engage in.
We observe the building in of the patient voice, at a much earlier stage, and believe this to be an encouraging move, which, of course, follows the duty of candour.
Direct involvement of patients, and those affected, such as families and healthcare professionals, is reflective of a modern approach. This, linked with existing governance arrangements, means a potent combination of voices, which should support and help improve patient safety in the organisation.
Ownership of areas for improvement arising from the action plan, and auditing in the future of those action points, are critical in our view, to the success of PSIRF. We have a great opportunity for reflection and meaningful learning.