PSIRF Transition Services

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

Below are examples of how we can support your organisation through the transition. The italics are a sample of the new requirements your organisation will need to address.

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1. Board Development – Engagement sessions to explore and consider strategies to embed new responsibilities and accountability. Understand the wider requirements and their inter-connectivity including CQC’s expectations.

Sample Requirements:

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.

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.

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2. CEO Insight – Gain an understanding of the implications of specific accountabilities and support in identifying potential strategies for effective implementation and compliance.

Sample Requirements:

• 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.
• Ensures that the organisation complies with internal and external reporting/ notification requirements.

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3. Risk, Governance & Patient Safety Teams Development – Independent and impartial advice for developing implementation plans, metrics and creation of engagement platform. Determine baseline data and identify key learning priorities for improvement cycles.

Sample Requirements:

• 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 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.

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4. Incident Investigation Priorities – Expert Incident Data Analysis – Impartial actuarial expertise and statistical analysis of clinical and risk management data. Outputs to identify where to best priorities for learning and improvement. Plans developed in conjunction with cost benefit analysis.

Sample Requirements:

• To support local improvement, organisational leaders also must determine which categories of incident are priorities locally and require a PSII (Patient Safety Incident Investigation). They should do this by reviewing past incident data (from the last three to five years where available) to identify those incidents representing the most significant risks.
• Analyse patient safety incident reporting data over the last three years alongside patient safety concerns highlighted through complaints, mortality review processes, coroners’ inquests, litigation claims, infection prevention and control-related audits, and other relevant clinical audits completed over the previous 12 months.
• Analyse incidents by frequency of occurrence, severity and cost.

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5. PSIRF Gap Analysis – Resources, Process & Quality – Facilitate current and future state analysis of processes, resources and improvement strategies. Reviews designed to stress test current resources capabilities.

Sample Requirement:

• Refer to the national PSII standards to identify gaps in dedicated PSII personnel, seniority, PSII skills, etc to enable delivery of the potential PSII programme.

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6. PSIRF Implementation Strategy – Expert and impartial support in creating a bespoke, evidence based PSIRF Plan. Assist in preparation for Plan website publication, engagement and implementation.

Sample Requirements:

Using the following steps, develop a strategic plan to address the above findings:

• Plan consultation work with commissioners and other stakeholders, including patient and staff groups, to review and develop a prioritisation plan for local PSIIs.
• Develop a prioritised register of patient safety incident types by identifying and ranking them according to the risk they present locally (severity, likelihood, concern, cost etc) and the opportunity they present for new knowledge and improvement. Use the register as an active document.
• Publish a summary PSIRP on the organisation’s website.

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7. Collaborative Learning: Cross-system Investigations – Engagement support to design positive, mutually beneficial sharing and learning processes working with Commissioners/STPs/ICSs/ICPs.

Sample Requirements:

Supporting cross-system patient safety investigations: (1) All commissioning systems (and/or STPs or ICSs/ICPs) must develop their capacity and capability, where 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.

Regional Investigation 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.

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