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.
Effective Recommendations and Actions
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:
- appropriately training staff in investigation or review of patient safety incidents for learning and giving them enough time to conduct a meaningful PSII or review of system safety
- the board and leaders throughout the organisation constructively challenging the strength and feasibility of recommendations to improve underlying system issues.“
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.