Leadership Readiness for Heightened Accountability

Board Briefing >> CQC Assessment >> Board Accountability >> Standards & Cross-System Learning >> PSIRF Transition Services

This requirement is key. Helpfully some broader considerations are explored through a set of questions that the PSIRF suggests leaders should ask themselves.

“Questions leaders should ask to support review:

• How many of our staff report incidents? (sources a,b)
• Do staff think the procedures for reporting incidents are fair and effective? (source a)
• Do staff feel confident and secure when they raise concerns? (source a)
• Does our board agree what the highest risk/priority areas are? (sources c,d,e)
• Have the highest risk/priority areas across services and/or organisational boundaries been identified? (sources d,e)
• Are those affected (patients/families/carers and staff) appropriately supported? (source f)
• Are those affected (patients/families/carers and staff) appropriately involved? (sources f,g,h) (sources: feedback from those affected by patient safety incidents)
• Are staff appropriately trained in relevant disciplines? (source i)
• Are identified remedial actions completed? (sources e,j)
• Are repeat incidents measurably and sustainably reduced once actions are completed? (source e)

Sources: a, NHS staff survey; b, National Reporting and Learning Explorer Tool; c, relevant board meetings; d, organisational strategies for improvement; e, reports on quality improvement activity; f, feedback from those affected by patient safety incidents and staff
Page 38 PSIRF Introduction

These questions are important, and we could add more. Some organisations will be able to positively answer the questions above. We suggest you also consider the following – how to create an evidence base?

The PSIRF states:

“Providers should agree their Patient Safety Incident Response Plans with their lead commissioners and publish a summary document on their websites, followed by annual reports of PSII activity and improvement plans. Publication should align with related information about Learning from Deaths where applicable.

Leaders must be able to demonstrate how the organisation:

• ensures those affected by patient safety incidents (including patients, families and staff) are effectively: supported involved in the response to incidents
• ensures staff involved in patient safety incident response and PSII roles are properly trained
• monitors (on an annual basis) the balance of resources going into patient safety incident response and PSII versus improvement
• evaluates (on an annual basis) whether actions in response to patient safety incidents have measurably and sustainably reduced risk.“

The last point is critical, requiring evidence that your Patient Safety Incident Response Framework is fit for purpose, and that all systems, processes, policies are delivering improved safer care. This may become a new measure by which providers could be held to account. 

In other words, ‘we have given you the Framework now prove you have made it work’ – not unreasonable, but complex and time-consuming. From our experience we know clinicians want to learn and they want the organisation to learn, however this requires genuine, meaningful and focussed engagement – this will then deliver long-lasting improvement.

The Framework’s masterstroke is baked-in accountability at the most senior of levels. The clear stipulation of ‘R&R’ (which obviously does not mean rest and relaxation) but instead roles & responsibilities, this approach will go a long way in elevating the importance of learning from incident. The burden this will place on boards should not be underestimated, though ultimately should be welcomed by all.

“Appendix 2: Roles and responsibilities, page 62 PSIRF Introduction
Roles, responsibilities and accountability need to be clear to ensure an appropriate response to patient safety incidents.

 Trust boards (including board quality sub committees) will be held to account for the following:

• Ensure that the patient safety incident response framework (PSIRF) is implemented from board to ward.
• Ensure that wider strategy development and implementation is aligned with the principles and requirements of the PSIRF.
• Take responsibility for leading the development of a just, open and learning culture within the organisation – and for role modelling the behaviours required to achieve this.

Chief Executive will be held to account for the following:

• Overall responsibility for ensuring the organisation has processes that support an appropriate response to patient safety incidents (including contribution to cross-system/multi-agency reviews and/or patient safety incident investigations (PSIIs) where required).
• Overall responsibility for ensuring the development of a patient safety reporting, learning and improvement system.
• Ensures that systems and processes are adequately resourced: funding, management time, equipment and training.
• Appoints executive lead for supporting and overseeing implementation of the PSIRF.
• Approves publication and ongoing review of the organisation’s patient safety incident response plan (PSIRP).
• Ensures that the PSIRF, patient safety incident reporting data, patient safety incident investigation data, findings, improvement plans and progress are discussed at the board’s quality subcommittee.
• Ensures that the organisation complies with internal and external reporting/ notification requirements.
• Acts as spokesperson in complex/high profile cases where the media/public is engaged.

Governors (where applicable) will be held to account as follows:

Hold the board and non-executive directors to account for:

• ensuring implementation of the PSIRF from board to ward
• developing a just, open and learning culture within the organisation – and for role modelling the leadership behaviours required to achieve this.“

We found it reassuring to see that Governors have been included, however the role itself may require remodelling in some organisations, and greater thought as to the training of Governors may also need to be considered.

We now consider the role of the individual tasked by the Board to ensure the PSIRF works as intended. As can be seen from the undernoted, this is a considerable role, and therefore Boards will need to carefully consider whom fulfils it.

“Executive lead for supporting and overseeing implementation of the PSIRF, this may be the person with overarching responsibility for quality or more specifically patient safety. They must be a member of the board or executive team and equipped (through training and professional development) with up-to-date safety skills, knowledge and experience, including conduct of patient safety review and investigation; knowledge of and appropriate responses to human factors; application of ‘being open’ and Duty of Candour principles; systems thinking/systems-based design; and quality improvement practices (including leadership for improvement).

• Ensures that the organisation has processes that support an appropriate response to patient safety incidents (including contribution to cross-system/multi- agency reviews and/or investigation where required).
• Ensures that processes for preparing for and responding to patient safety incidents are reviewed as part of the overarching governance arrangements.
• Ensures that the executive and non-executive team can access relevant information about the organisation’s preparation for and response to patient safety incidents, including the impact of changes following incidents.
• Oversees development and review of the organisation’s PSIRP.
• Agrees sufficient resources to support the delivery of the PSIRP (including support for those affected, such as named contacts for staff, patients, families and carers where required).
• Ensures that the Duty of Candour is upheld.
• Ensures that the organisation complies with the national PSII standards.
• Establishes procedures for agreeing patient safety investigation reports in line with the national PSII standards.
• Develops professional development plans to ensure that staff have the training, skills and experience relevant to their roles in patient safety incident management.
• Provides leadership, advice and support in complex/high profile cases.
• Liaises with external bodies/supports the chief executive as a spokesperson for the organisation as required.“

Ultimately at the heart of the PSIRF, is the way an incident review is undertaken (please note we do not call them investigations – we prefer learning review).

The sign off process for a completed incident review is becoming a more rigid, which we fully support and addresses the issue of little process governance in some organisations.

“Patient safety incident investigation
This framework places the responsibility for the sign-off of locally led (that is, provider-led) PSIIs with the board(s)/leaders of the organisation(s) involved. This means that someone who meets the training requirements for PSII and oversight should be responsible for reviewing a PSII report in line with the  national PSII standards and signing it off as finalised, all overseen by an executive who meets the training requirements for PSII and investigation oversight.“

SOURCE: Page 53 PSIRF Introduction

The Bigger Picture

The following graphic neatly sums up the vision of how the systems will interconnect from a governance perspective. How this will work in practical terms remains to be seen but we support the theory and logic.

Organisational responsibilities for an effective governance structure

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