New Patient Safety Incident Response Framework (PSIRF) published by NHS England - a fundamental shift in the investigation of patient safety incidents

NHS England has published a new Patient Safety Incident Response Framework, representing a significant change in how NHS service providers are expected to investigate patient safety incidents. What are the changes and how will NHS service providers be affected?

Background

In July 2019 NHS England published its NHS patient safety strategy, announcing the intention to implement a new Patient Safety Incident Response Framework (PSIRF) to replace the Serious Incident Framework (SIF), first introduced in 2015. The decision to make changes was said to be prompted by compelling evidence from various sources that organisations were struggling to deliver the SIF.

The new PSIRF was published on 16 August 2018, and for those required to comply, the expectation is that the framework should be implemented in full within 12 months of September 2022.

Organisations affected

Implementation of the PSIRF is a contractual requirement for organisations considered service providers under the NHS Standard Contract. This includes acute, ambulance, mental health, and community healthcare providers as well as maternity and specialised services.

Organisations that are not NHS Trusts who provide NHS-funded secondary care under the NHS Standard Contract (such as independent provider organisations) are required to adopt the framework for all aspects of NHS-funded care. Implementation is optional for primary care providers, such as GPs.

Overview of the new framework

The PSIRF seeks to move away from a focus on current thresholds for ‘Serious Incidents’. There is also a shift towards proportionate identification of system issues, with a requirement to increase support for those affected by patient safety incidents.

Organisations are required to develop a thorough understanding of their patient safety incident profile, ongoing safety actions and established improvement programmes. The PSIRF supports the development and maintenance of a patient safety incident response system that has four key aims:

1. Compassionate engagement and involvement of those affected by patient safety incidents.

There is a focus on the need to engage both patients and staff. Organisations must put in place policies addressing the engagement of people affected by incidents, with a focus on apologies, timing, openness and listening.

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

There is a move away from identification of simplistic causes of incidents, with a system rather than person focussed approach. Organisations are to be supported with the execution of these new approaches via published tools and guides.

3. Considered and proportionate responses to patient safety incidents.

Save for in respect of some specific remaining categories (such as ‘never events’) there are no longer thresholds for which incidents require investigation. It is observed that the NHS has finite resources, and the onus will be service providers to identify themselves whether risks are already being appropriately managed. Organisations may also seek to investigate incidents that would not previously have met the criteria for mandatory investigation (such as ‘near miss’ incidents).

4. Supportive oversight focused on strengthening response system functioning and improvement.

Service providers must be open with information relating to patient safety incidents and findings. There is an expectation of collaboration with regulators and Integrated Care Boards (ICBs).

Implementation

NHS England has published a detailed national preparation guide, supported by further guidance documents, tools and templates. The preparation guide is informed by insights from 17 early adopters, and provides a detailed month by month guide on what service providers should aim to achieve during the12 month transition period. This includes advice on engagement, programme management and implementation.

Comment

The PSIRF does not represent a different version of the current investigation format, but rather a completely different system altogether. Implementation by NHS service providers will not be achieved by a change in policy alone. There is a need to design a whole new set of systems and processes.

Clearly, implementation will be a significant undertaking. NHS organisations may be concerned about how they can put the framework into effect within 12 months.

Although the implementation will be challenging, once in place, the framework should be welcomed as an opportunity. NHS service providers will have more flexibility and autonomy over what they investigate and how they ensure effective learning in a way which best fits with their own organisation’s specific service provision and challenges. The focus on engagement with patients and staff should also help with the advancement of a fair and open culture.

We have extensive experience of helping NHS service providers with incident investigations. If you would like help and assistance with the implementation of the PSIRF, please contact Claire Petts.