Search the hub
Showing results for tags 'PSIRF'.
Found 226 results
-
EventThe Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
-
EventThis virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
-
Content ArticleProfessor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
-
Content ArticleInnovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice, but little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the Covid-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which can be accessed via the link to the paper). These provide: an introduction to the AAR facilitation process a simulation of a facilitated formal AAR techniques for handling challenging situations that may arise in an AAR reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.
-
Content Article
In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024. -
Content ArticleA patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time. This NHS England document provides an overview of patient safety incident investigation stages, tips and suggested structure for analysis.
-
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. Tracey talks about how her lived experience of navigating the criminal justice and healthcare systems as a victim of serious violent crime has shaped her role as a Patient Safety Partner. Tracey is passionate about speaking up for patients and families, and she highlights the need to prevent compounded trauma by ensuring services meet their needs. She calls for a more joined-up approach between public services and outlines the importance of clear, compassionate communication following a patient safety incident or other traumatic event. -
Event
NHS Complaints Summit
Patient Safety Learning 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. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email kate@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #NHSComplaints -
Content Article
The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder. -
Content Article
From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident. -
Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. Homerton University Hospital have shared a presentation on how they are going to implement LFPSE into Datix, a quick reference guide and a screen saver they are using to introduce it to staff. Others may find the resources useful and can adopt/adapt them in their own organisations. They can be downloaded from the attachments below. Additional resources on the hub: CSH Surrey share their presentation slides on LFPSE and Datix.
-
Content ArticleThis CPD course, run by Health Services Safety Investigation Branch (HSSIB), is aimed at those who lead investigations and other learning responses and those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course meets the minimum training requirement of this specific element of the new PSIRF. This course will begin on Friday 24 November and will close on Friday 24 May 2024. You will only have from the time you enrol to the close date to complete this course. The course includes: An introduction to complex systems, systems thinking and human factors Investigation practice such as interviewing, capturing work as done, use of a systems framework (SEIPS), data synthesis, and report writing Developing effective safety actions and recommendations Engaging and involving those affected by patient safety incidents. HSSIB courses are currently available free of charge to NHS staff in England, with a focus on those with patient safety and investigation roles.
-
Event
PSIRF embedding webinar 6
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Event
PSIRF embedding webinar 4
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Event
PSIRF embedding webinar 3
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Event
PSIRF embedding webinar 2
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Peter Ledwith, Deputy Director of Governance, East Cheshire NHS Trust Liam Oliver, Senior Patient Safety Manager, Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Register -
Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. LFPSE introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment. LFPSE fields can now integrated into Datix incident form, and the information is uploaded to the national database upon the completion of an incident report. After the reviewing manager’s and Patient Safety Team review, any changes are automatically re-uploaded and the information updated in the national database. CSH Surrey share their presentation slides on LFPSE and Datix.
-
News Article
New approach to safety incidents will see fewer investigations
Patient Safety Learning posted a news article in News
Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202 -
Content ArticleJudy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.
-
Content ArticleIn this blog, Mark Amphlett, clinical negligence specialist, looks at the recently launched Patient Safety Incident Response Framework (PSIRF), the aims of moving away from the Serious Incident Framework, and the challenges of implementation.
-
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. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.- Posted
- 1 comment
-
3
-
- (and 7 more)
-
Content ArticleTracey Herlihey, head of patient safety incident response policy, in the NHS England national patient safety team, is joined by Vicky Ainsworth, a communications lead at Manchester University NHS Foundation Trust and Stuart Kaill, from Health Innovation Manchester, to discuss ways of communicating about large scale change projects in NHS organisations. The podcast explores Vicky’s experience of leading on communications for a large scale change project in Manchester, with a specific focus on sharing advice and suggestions relating to communicating the changes related to the Patient Safety Incident Response Framework (PSIRF). It includes expert tips on how to communicate large scale change to different audiences as well as within both large and small organisations.
-
Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
- Posted
- 4 comments
-
3
-
- (and 8 more)
-
Content ArticlePatient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
-
Content ArticleIn this episode of the What the HealthTech? podcast, Radar Healthcare's Chief Product Officer Mark Fewster speaks to Helen Hughes, Chief Executive of Patient Safety Learning. to get the lowdown on NHS England's new Patient Safety Incident Response Framework (PSIRF). Helen talks about how PSIRF is going to drive an open and just culture, what can be expected after the transition and why the implementation process is key to PSIRF's success. Listen on Spotify Listen on YouTube
