With many NHS organisations now marking two years into their Patient Safety Incident Response Framework (PSIRF) journey, I wanted to reflect on the successes, challenges and sometimes unforeseen issues surrounding the framework's implementation.

The PSIRF, introduced nationally in 2022, purportedly set a new gold standard for how the NHS responds to patient safety incidents. The framework was designed to move away from a blame culture and towards more systems-based learning approaches. Importantly, ensuring families were more included in the process of an investigation, reducing repetitive incident investigations and in turn trying to impact the ever-increasing burden of litigation upon the NHS.  

Now two years on, the Health Services Safety Investigations Body (HSSIB) has published its report on findings from the implementation of PSIRF. Its conclusions outlined a number of both interesting and anticipated outcomes.

Many of the findings chime with some of Niche's early concerns on areas for potential misalignment of the framework, with areas for improvement highlighted in several key aspects.  

Variation in implementation

A notable theme highlighted by the HSSIB report is ‘variation' surrounding implementation. Within this is variation in funding and resources, support, application, leadership, effectiveness and engagement. Particularly pertinent is the need for more financial support to ensure the best incorporation of the framework; at the moment it could be bluntly estimated as being a halfway successful implementation.

It is clear some organisations have struggled with the resource to implement the framework successfully where multiple different pressures and priorities are competing. 

PSIRF particularly, is quite a radical departure from the traditional and more linear methods of investigating and so perhaps the psychological shift in mindset has also been underestimated. SEIPS (Systems Engineering Initiative for Patient Safety) approaches involve much more lateral thinking, which lend themselves well to panel and group inputs. Instead, there is often one lead for implementation who is valiantly trying to implement a whole-scale paradigmatic shift, the resource for which may well have been vastly underestimated.

Data availability is also an area where organisations have struggled. PSIRF depends upon the ability to spot themes and trends and to use these to underpin strategic approaches. But this in turn relies upon consistent, accurate and timely inputting into whichever incident management system is in use. Good data ‘out' is entirely reliant upon good data ‘in'. 

Needs versus wants 

While systems-based learning and avoiding individual blame is the cornerstone approach of PSIRF, this doesn't always meet the expectations of families or coroner processes. As we know, coroner's courts will always require a forensic, antecedent investigation report; they are not particularly seeking system approaches. The requirements of a coroner have primacy over an organisation's own preferred patient safety response. Families too want to know truth and facts have been surfaced by an investigation and will unlikely be assured by a ‘thematic review'.

There is some inevitability that staff will prefer systems-based approaches which avoid blame but the focus on the avoidance of blame (as opposed to fair blame) can sometimes leave families feeling cheated of accountability.

While root cause analysis has moved on as a methodology, there should still be space for the acceptance of a ‘root cause' issue if one clearly exists, ideally, this should be linked to an issue of the ‘system', but it is hard to allocate this, if it is not in fact the case. Just culture approaches are not encouraging an abdication of individual responsibility but the recognition that people are imperfect and they are working within an imperfect system.

How can organisations improve delivery?

Some organisations reported very little had changed since the introduction of PSIRF and they were still struggling with enhanced engagement practices, and that as long as they had fulfilled duty of candour towards families, then this had sufficed. 

How and where organisations can do more for families remains a question that needs more focus. On one hand there was an appetite for dedicated family mediation support, on the other hand families felt this sometimes added an additional barrier between them and the ‘system'.

Overall, the key to successful delivery of PSIRF approaches is an organisation's ability to deploy the most appropriate and proportionate responses to incidents. Yet, care should be taken not to downgrade the correct responses at the cost of speed and efficiency. Internal organisational approaches lend themselves well to thematic review, whereas, when a more forensic and detailed analysis is required, an independent investigation is often the most appropriate response.