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Showing results for tags 'PSIRF'.
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Content ArticleSeminar from Tracey Herlihey, NHS England, on the Patient Safety Incident Framework (PSIRF).
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Content ArticleIn this webinar, Tracey Herlihey, Head of patient safety incident response policy, NHS England, looks at how the Patient Safety Incident Response Framework (PSIRF) is changing the culture amongst healthcare workers and what this means for individuals. Dr Henrietta Hughes discusses the events leading up to the creation of the Patient Safety Commissioner role, her priorities and the role of leaders. She also explores the importance of ‘what matters to you'—that is, why we must listen to patients and what happens if we don’t.
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Content ArticleThis film demonstrates how using SEIPS can help illuminate contributory factors within a work system, such as unconscious bias, stereotyping, workload, incivility, societal pressures and environmental factors under the six entity headings. Staff watch an animated explanation of SEIPS and then a short fictional maternity scenario looking out for relevant contributory factors. After viewing the film staff take part in a facilitated discussion to reflect. It is hoped that those using this film will be able to build on this experience, and then reflect on their own clinical service through the SEIPS lens, as taking a systems-based approach will strengthen a Just Culture, reduce blame and supports the PSIRF process.
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Content Article
The Patient Safety Partner (PSP) role was introduced in 2022 by NHS England as part of its Framework for involving patients in patient safety and National Patient Safety Strategy. Trusts across England must recruit at least one Patient Safety Partner. They can be patients, carers or members of the public who want to support and contribute to an organisation’s governance and management processes for patient safety. In this blog, we draw on discussions from the Patient Safety Partners Network and a recent workshop, to highlight the need for role clarity and guidance for Patient Safety Partners. We share insights from areas of good practice, where the role has been well supported and integrated locally. These examples show how clarity and guidance has helped remove barriers, enabling Patient Safety Partners to have a positive impact for patient safety, as intended. -
EventAn After Action Review is a facilitated discussion following an event to understand what happened and why, and how it could be improved from the perspective of those who were involved. There is an emphasise on facilitation of active awareness and self learning to lead to lasting change and improvement. AARs are included as an investigation and learning tool under the Patient Safety Incident Response Framework (PSIRF). https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email frida@hc-uk.org.uk Follow this conference on X @HCUK_Clare #AfterActionReviews hub member receive a 20% discount. Email info@pslhub.org for discount code.
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EventThis conference focuses on patient involvement and partnership for patient safety including implementing the National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework. https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-involvement or email frida@hc-uk.org.uk Follow this conference on X @HCUK_Clare #PatientPSP2024 hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventThis course is aimed at those who wish to lead and conduct thematic reviews and those who are part of an themed review team. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in thematic reviews when you return to your organisation. “A themed review may be useful in understanding common links, themes, or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases…Grouped incidents, for example from the same portfolio like pressure ulcers, falls or deteriorating patient, may benefit from a themed review because they take the same safety concern and identify different reference cases and contexts. This helps the organisation make sense of the safety concern at different points of the system and with different aspects of variability… Outputs of themed reviews can highlight these problems and identify safety recommendations. Themed reviews may provoke more questions than answers, and therefore may be best placed to link in to a quality improvement project for ongoing monitoring and PDSA-style improvement cycles. A themed review should be viewed as a diagnostic tool to help diagnose problems in the system, and therefore doing a themed review should always result in some improvement efforts after this diagnosis." Dr Samantha Machen Head of Patient Safety Incident Response University Hospitals Sussex NHS Foundation Trust Themed Review Template This conference will enable you to: Network with colleagues who are working to improve patient safety through the use of Thematic Reviews. Learn from outstanding practice in delivering and conducting Themed Reviews. Reflect on national developments and learning. Understanding when thematic reviews are useful under PSIRF. Attend a whole morning masterclass aimed at improving your skills in thematic followed by an afternoon with best practice examples. Develop your skills in writing thematic reviews including deductive and inductive thematic analysis, triangulation of information and understanding potential barriers. Test your skills through simulated thematic reviews case studies. Understand how you can improve learning from thematic reviews. Engage and involve Patients and Families in Themed Reviews. Identify key strategies for change and improvement. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventThis course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Register hub members receive a 20% discount. Please email info@pslhub.org for the discount code.
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EventuntilThis course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Register hub members receive a 20% discount. Please email info@pslhub.org for the discount code.
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Content Article
The Patient Safety Management Network (PSMN) started on a Friday afternoon in June 2021 as three people in a Zoom meeting. In this interview, PSMN founder Claire Cox reflects on why the network has grown to have over 1600 members and what it has achieved over the past three years. She outlines how the network has fostered a safe space for staff to raise issues and shares feedback from members about what they love about the PSMN.- Posted
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Content Article
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In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, explains how she became involved in Appreciative Inquiry and asks the question: what could Appreciative Governance start to look like in the NHS and what small steps can we all do to achieve that together? -
Content ArticleCaring Corner is a podcast hosted by Katy Fisher and Kayleigh Barnett sharing real stories of Appreciative inquiry in health and care.
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EventuntilSince the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses. -
News Article
‘Burdensome’ patient safety inquiries taking up too much time, says NHSE chief
Patient Safety Learning posted a news article in News
NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleThis template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256
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EventJoin Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in collaboration with Radar Healthcare for an engaging discussion on Learning from Patient Safety Events (LFPSE) and the Patient Safety Incident Response Framework (PSIRF), highlighting their combined impact on patient safety improvement. This webinar will delve into pivotal aspects crucial for integrating LFPSE and PSIRF into your incident and reporting software, including: User-Centric Approach: Understand the significance of aligning LFPSE and PSIRF principles with the end-user's perspective, ensuring a seamless and intuitive experience. Success Story: Learn how GSTT implemented both LFPSE and PSIRF, surpassing standard levels of incident reporting and advancing patient safety practices. Data Empowerment: Discover how GSTT was able to address its patient safety priorities and facilitate the provision of critical data to the national patient safety improvement programs led by NHSE. This session will spotlight how GSTT adapted to new processes and frameworks like LFPSE and PSIRF, contributing to both national and local safety initiatives. Speakers: Charles Martin, Trust Head of Risk and Quality Assurance - Guy’s and St Thomas’ NHS FT Paul Johnson, CEO - Radar Healthcare Jack Forshaw, Project & LFPSE Lead - Radar Healthcare Chair: Jon Hoeksma, CEO - Digital Health Register
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EventThis training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Event
Duty of Candour
Patient Safety Learning posted an event in Community Calendar
This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. WHO SHOULD ATTEND Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. KEY LEARNING OBJECTIVES Understanding the importance of communication in a clinical context and the role of the duties of candour. Appreciating the difference between the statutory and professional duties of candour. The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent. Understanding the process when the duty of candour is triggered. Understanding the relationship between the duty of candour and fault / blame / liability. The legal implications of an apology and what makes a good apology. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Mark talks to us about his role as a National Patient Safety Partner (PSP). He explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. He also highlights the challenge of implementing the Patient Safety Incident Response Framework (PSIRF) across a diverse range of providers and the complexities arising where PSIRF interfaces with systems and processes outside of the NHS. -
Event
After Action Review Masterclass
Sam posted an event in Community Calendar
An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code. -
Event
NHS Complaints Summit
Sam posted an event in Community Calendar
This National Virtual Summit focuses on the New PHSO National NHS Complaint Standards which are now being used and embedded into the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect how involving people and their families in complaints and integrating the process with the new Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email frida@hc-uk.org.uk for further information. Follow the conference on Twitter @HCUK_Clare #NHSComplaints hub members receive a 20% discount. Email info@pslhub.org for the discount code.
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