Author: Cheryl Blundell, Consultant at Capsticks

The new Patient Safety Incident Response Framework (PSIRF) replaces the 2015 Serious Incident Framework (SIF) and governs the investigation of patient safety incidents in NHS-funded healthcare. It represents a ‘sea change’ in how the NHS responds to patient safety incidents (PSIs), to achieve learning and improvement.

Key principles

Unlike the SIF, the PSIRF is non-prescriptive regarding what to investigate. Instead it:

  • Advocates a co-ordinated and data-driven approach to PSIs.
  • Prioritises compassionate engagement with those affected – patients, families and staff.
  • Embeds PSI response within a wider system of improvement.
  • Prompts a significant cultural shift towards systematic patient safety management.

Status of the PSIRF and transition period

Adoption of the PSIRF is a contractual requirement for any services provided under the NHS Standard Contract: acute, ambulance, mental health, community, maternity and all specialised services, plus independent providers of NHS-funded care. Organisations are expected to transition from the SIF to PSIRF by autumn 2023. Primary care providers are not required to adopt PSIRF at the moment, but they can do so if they wish.

PSIRF essentials

Organisations are required to develop a thorough understanding of:

  • Their PSI profile
  • Ongoing safety actions (in response to recommendations from investigations), and
  • Established improvement programmes.

Where do we start?

Organisations use a planning exercise to inform what their proportionate response to PSIs should be. As the PSIRF approach is flexible it will adapt as organisations learn and improve.

Safety and learning

The PSIRF supports the development and maintenance of an effective PSI response system that integrates four key aims:

  1. Compassionate engagement and meaningful involvement of those affected by PSIs. Existing policies to support this are an integral part of this aim.
  2. Application of a range of system-based approaches to learning from PSIs. Organisations are encouraged to use the national system-based learning response tools and guides (or system-based equivalents) to explore contributory factors to a PSI (or cluster) and to inform improvement.
  3. Considered and proportionate responses to patient safety incidents.
    1. Some PSIs (e.g. never events) require a PSI investigation to learn and improve.
    2. Others require specific reporting and / or review processes to be followed (e.g. PSIs which meet the ‘each baby counts’ and maternal deaths criteria to be referred to the Healthcare Safety Investigations Branch (Special Health Authority once set up).
    3. The PSIRF sets no further rules or thresholds (save in relation to responding proportionately). Incident response activity may include, for example, a thematic review of past learning responses to inform development of a safety improvement plan. If an organisation and its Integrated Care Board (ICB) are satisfied that risks are being appropriately managed and monitored in relation to a PSI type, an individual PSI investigation isn’t necessary. The response can be limited to engaging with those affected and recording that the incident occurred.
  4. Supportive oversight and collaboration to strengthen response system functioning and improvement. Healthcare organisations providing and overseeing NHS-funded care must collaborate to provide an effective governance structure. The PSIRF expects ICBs to facilitate collaboration at both place and local system level. Accountability for the quality of learning responses to individual PSIs rests with provider leaders.

What this means for you

There is plenty of guidance accompanying the PSIRF, including a helpful preparation guide which sets out suggested tasks and timeframes. Healthcare organisations will need to:

  • Review their current PSI profile. This might encompass ongoing safety actions from serious incident investigations and the efficacy of current improvement programmes.
  • Review current PSI policies, procedure and plans.
    • Policies will need to integrate the PSI response with clinical governance, HR and complaints management.
    • Ensure a mechanism is in place to update plans regularly based on new learning. Plans must be published on your organisation’s website.
    • Consider how to optimise engagement with stakeholders such as local coroners and patient groups, to ensure their needs are included.
  • Commence PSI response planning exercise required by the new PSIRF.
  • Plan recruitment and training and skills development.
    • Learning response leads will require specific knowledge and experience.
    • The guidance is explicit on how training can support development of a just culture and reduce the ethnicity gap in rates of workforce disciplinary action.
    • Online training will be available from HSIB later in 2022.

How Capsticks can help

The PSIRF needs to be seen in the context of the wider quality, governance and safety landscape. We can support your training programmes and policy reviews. We will be helping you to ensure that the adoption of the PSIRF is a success and that it swiftly becomes embedded alongside existing policies and duties such those linked to candour, complaints and CQC compliance.

We will shortly be rolling out a series of national seminars working alongside early adopters of the PSIRF to deliver practical tips and case studies for our clients. In the meantime, please contact Adam Hartrick, Amy Holden, Georgia Ford or Ian Cooper if you would like to discuss the new framework or find out more about how we can support you.