SYSTEM-WIDE LEARNING SHOWCASE

Summary

The ICB Quality and Patient Safety Team hosted a System Shared Learning Showcase Event to share the experience of the implementation and ongoing embedment of the Patient Safety Incident Response Framework (PSIRF). The event brought together system wide stakeholders to drive sustainable improvement collaboratively in patient safety and experience across Coventry and Warwickshire.

The Patient Safety Incident Response Framework (PSIRF) was published in August 2022, replacing the Serious Incident Framework (SIF), it promotes a proportionate approach to responding to patient safety incidents by ensuring resources allocated to learning are balanced with those needed to deliver improvement.  

PSIRF represents a fundamental shift in how the NHS responds to patient safety incidents for learning and improvement. Unlike the SIF, the PSIRF is not an investigation framework that prescribes what to investigate.

Instead it:

• advocates a co-ordinated and data-driven approach to patient safety incident response that prioritises compassionate engagement with those affected by patient safety incidents

 

• embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management

 

PSIRF works alongside the NHS Patient Safety Strategy which describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.

 

Why change was needed

All organisations with an NHS standard contract were expected to adopt PSIRF. This includes Independent Providers of NHS funded care. Primary Care and some smaller providers will remain under the SIF until it is decided that they will transition into PSIRF.

 

To fulfil our roles and responsibility requirements, the ICB:

• Collaborated with providers in the development, and continue to support the maintenance and review of their patient safety incident response policies and plans,
• We agreed initial patient safety incident response policy and plans, as well as producing our own,
• We continue to oversee and support the effectiveness of systems in achieving improvement following patient safety incidents,
• We support co-ordination of cross-system learning responses,
• We share insights and information systemwide to improve safety.

 

The ICB held workshops throughout 2023 to support the provider’s implementation and transition into PSIRF. All but one provider transitioned on 31^st December 2023, with the remaining provider transitioning on 1^st April 2024. From this date the workshops evolved into learning events of which two were held in 2024, these were well attended and received.

 

What's next? 

The ICB will ensure there is system learning throughout the year with feedback being presented at the 6 monthly System Shared Learning Showcase Events. Representation at this event will be system-wide and include, for example Providers, Independent Providers, Primary Care, Local Authority, Coroners & the CQC.