Board Briefing >> CQC Assessment >> Board Accountability >> Standards & Cross-System Learning >> PSIRF Transition Services
The CQC’s expectations are a good starting point. It appears CQC will begin looking at how providers respond and adhere to this new regime. The framework states:
“The CQC’s assessment of a provider’s leadership and safety considers an organisation’s ability to respond effectively to patient safety incidents, focusing on whether change and improvement follow its response to patient safety incidents. Inspection teams will apply this PSIRF when assessing the strength of an organisation’s systems and processes for preparing for and responding to patient safety incidents, as well as nationally agreed quality metrics. Incident data will not be inappropriately used as a measure of safety performance.
CQC will expect to be informed (via the regional relationship lead) of high profile and complex incidents, as part of the co-ordinated response. CQC will focus on ensuring that the provider can support the needs of those affected and take meaningful action in response to an incident’s causes.”
SOURCE: Page 61 PSIRF Introduction
Clearly, assessing the strength of provider’s systems and processes will play a critical role from a CQC perspective. Organisations will be assessed on their evidence base, in responding to incidents – including the reduction of incidents where lessons learnt were successfully imbedded through effective mitigations.
Consider that the output from an incident review maybe to implement a change or even several changes, it is critical that these are effectively monitored to establish if they are working as intended, and not (as we have seen before) creating negative unintended consequences. Unfortunately, often it is assumed that mitigations have been embraced by clinicians and are working as envisioned, however this is sometimes not the case. How an organisation recognises that and responds will be a key factor. Clinician engagement and input is critical to meaningful improvement.
Powerful guidance on learning and improvement within your organisation is outlined as follows:
“Those overseeing Patient Safety Incident Investigations (PSIIs) must ensure that recommendations drive a systems approach to improvement by:
SOURCE: Page 20 PSIRF Introduction
Clearly the board and other internal leaders will be expected to provide challenge, which is of course excellent, but will require some training as hitherto this may not have been expected of them.
To meet these new requirements – whilst also considering governance – the key will be how providers stress tests their response to an incident, especially how they support all involved.
Getting this right and evidencing it will be tricky, and some organisations may require independent and impartial support to navigate through and empower their leaders.
Lorraine works with healthcare providers to identify and learn from risks to improve patient safety. Her work focusses on shaping systems and processes to provide early warnings for proactive risk management. Client programmes are anchored in the principles of engagement, transparency and leveraging data. Meaningful frontline engagement, using elements of Design Thinking, has enabled clients to better understand functional and cultural issues that inhibit learning.
Lorraine has applied this in Acute, Community and Mental Health settings. She has collaborated with the Stanford Risk Authority (of Stanford University Hospitals) for more than seven years focusing on innovative risk management processes.
Lorraine has worked in healthcare for almost 20 years and is a managing director of Price Forbes Healthcare. Lorraine holds a BA in Political Science and Economics.
Mark’s specialist clinical risk management knowledge centres around medical facilities including: Acute Hospitals, Mental Health and Community health including in Primary Care.
Mark has advised various Government bodies such as, Dept of Health and Ministry of Justice, by sitting on specially convened panels and industry sector groups to advise on clinical risk and indemnity, within the UK healthcare environment and similar healthcare economies across Europe.
Mark has worked closely with the healthcare regulators assisting these bodies in reviewing and assessing clinical risk, within all aspects of Healthcare, including public, private, not for profit and charitable sectors.
Mark is a managing director of Price Forbes Healthcare and read Law at Cambridge University, where he gained an MA.