Standards & Cross-System Learning

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Given the evidence garnered by NHSI during their consultation process its summation is that for systemic, system-based learning and improvement it is necessary to set out clear standards and thorough guidance – for ALL providers to adhere toThis evens out the playing field but more importantly is the right thing to do – for patients and clinicians alike.

Overview of standards for local systems-based patient safety investigations in NHS-funded care

Patient Safety Incident Response Framework 2020: An introductory framework for implementation by nationally appointed early adopters, NHS England & NHS Improvement, March 2020

Learning Together

We applaud the PSIRF for placing an emphasis on cross-system learning. This is something that has been talked about for many years, however in reality rarely occurs and when it does, has mixed success/results. We hope learning as a shared mission will assist organisations in moving beyond fear (of liability and blame) and instead focus on reducing the recurrence of similar incidents.

The following excerpts are comprehensive in their ambition and will necessitate commissioning systems taking central roles and where required an independent regional investigation team assisting in driving collaborative sharing and learning.

“Supporting cross-system patient safety investigations:

(1) All commissioning systems (and/or STPs or ICSs/ICPs) must develop their capacity and capability, where these are insufficient, for co- ordinating cross-system investigation and have systems to recognise incidents that extend beyond local boundaries and may require co- ordination at a regional level.

SOURCE: Page 76 PSIRF Introduction

Regional teams will help co-ordinate cross-system PSIIs, primarily by working with commissioners (and/or STPs/ICSs/ICPs) to ensure they have the relevant systems to support these investigations at a local level and supporting co-ordinated and measured responses – both to take meaningful action against an incident’s causes and to meet the needs of those affected – to high profile or complex incidents. On occasion, regional teams will directly co-ordinate more complex, multi-organisation PSIIs where these cannot be managed at a local system level.

Related to this, the Regional Independent Investigation Teams (RIITs) will help identify those incidents highlighting system-based, cross-system issues that may require a centrally co-ordinated and independent PSII, such as a mental health- related homicide.

Where a system, or provider(s) within a system, experience significant challenges in responding to patient safety incidents, eg a breakdown of governance infrastructure across local systems or a spate of high-profile patient safety incidents, regional teams will work with relevant teams/individuals to determine how best to resolve identified problems.

All commissioning systems (and/or STPs or ICSs) must develop their capacity and capability, where these are insufficient, for co-ordinating cross-system PSIIs (to support the activities described below) and have systems to recognise incidents that extend beyond local boundaries and may require co-ordination at a regional level.

They must engage early with relevant NHS England and NHS Improvement regional leads where a PSII involves several different organisations or agencies within and across health economies spanning regional boundaries, to support co-ordination.”

SOURCE: Page 86 PSIRF Introduction

Ideally, this regional investigation expertise may eventually assist in the open sharing of proven mitigations across public and private sectors which is critical to enable long-term sustainability of the healthcare economy.

Additionally, with this deepened focus on capacity and capability coupled with the emphasis on measuring improvements (derived from investigations) could lead to better investigation quality oversight and tracking systems. Commissioners receive such varied quality of investigation reports that makes monitoring of the quality of services commissioned almost impossible.

We often find that clinical governance processes can (for some unfathomable reason) limit the dissemination of critical information and therefore learning. This is a real issue and requires full support, therefore we are heartened to read the following:

Clinical governance

The clinical governance of PSIIs needs to support ‘being open’. Findings should be disseminated to staff so that they can learn from patient safety incidents. A system of accountability through the chief executive to the board is needed to ensure changes are implemented and their effectiveness reviewed. Practice-based risk systems should be established in primary care.

Organisations need programmes to continuously learn from patients’ experiences of ‘being open’ and audits to monitor the implementation and effects of practice changes following a patient safety incident.”

SOURCE: Page 66 PSIRF Introduction

The Framework offers a host of helpful supporting documents, providing much more structured guidance than previous Serious Incident Frameworks. We whole-heartedly welcome the systems learning approach which focusses on how the incident occurred and how those involved are supported.

Obviously, clinicians are the most valuable facet of a healthcare provider and when care doesn’t go to plan, they need to know they are valued and that learning will take place. Clinicians don’t want their patients to come to harm and when asked they have the solutions to keep them safe.

The new framework is a huge step forward and should positively impact all those who deliver NHS funded services and may even be welcomed in a new era of co-operation between healthcare providers – regardless of whether they are a public or private provider.

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