PSIRF: The Patient Safety Incident Response Framework

Understanding and Implementing the Patient Safety Incident Response Framework (PSIRF)

This week we’re having a look at the new NHS Patient Safety Incident Response Framework (PSIRF). Whilst this is clearly relevant to our UK healthcare readers, I believe that the approaches and ideas within PSIRF are useful for many folks inside and outside healthcare. PSIRF encourages a shift in thinking, away from individual accountability and towards systemic change and learning from everyday work as well as incidents. Fundamentally, PSIRF recognises the need to establish psychologically safe cultures and practices *before* approaches such as Just Culture can work in practice. This article is a brief description of what PSIRF is and how it might be adopted, alongside my personal opinion about the impact of PSIRF on healthcare and other sectors, and is written from our experience of working with healthcare organisations alongside some expert advice.

Patient Safety Incident Response Framework (PSIRF)

The National Health Service (NHS) introduced the Patient Safety Incident Response Framework (PSIRF) in August 2022, introducing a new approach to handling patient safety incidents. Replacing the previous Serious Incident Framework, PSIRF signifies a fundamental transition in how the NHS responds to such incidents. It favours a systemic and qualitative investigative methodology over the more linear Root Cause Analysis (RCA) approach.

The preceding Serious Incident Framework required that any event which met predefined criteria necessitated an RCA – a process that could extend to 60 days. However, RCA, with its singular focus on identifying a root cause, often fell short in extracting meaningful learning. RCAs were required even for frequent events or those under ongoing investigation, and this led to a considerable burden on healthcare teams, potentially distracting and diverting people away from delivering and enhancing patient care. 

A Systems-Oriented Approach

PSIRF encourages a more qualitative, systemic perspective towards patient safety incidents. Investigations are seen as ‘windows’ into the system, dissecting how work unfolds and considering all the elements, from human to technological factors, in a sociotechnical system. The framework acknowledges that a day when an incident occurs may be the same as any other day: the processes and procedures may remain identical – it just so happens that an incident occurred on that day. The incident is regarded as a unique disruption in the ordinary course of operations. 

In fact, PSIRF expands the methodology beyond investigations to a range of methods to inform improvement, recognising that there is no “one size fits all”, and application of suitable learning methods to the situation provides for the most effective “learning responses”.

Additionally, PSIRF underscores the importance of engaging with all parties impacted by the incidents, considering the broader human implications. It acknowledges the effect on first victims (patients), second victims (friends and family), and third victims (hospital staff affected by the incident).

Ultimately, PSIRF encourages fewer, but higher-quality investigations. 

Learning Potential

Successfully implementing PSIRF entails a transformation of practices, increasing collaboration and breaking down silos. This requires cultural shifts, novel strategies and the implementation of more effective qualitative feedback loops. Most importantly, it requires, and will hopefully encourage, behavioural changes and communication improvements. PSIRF emphasises the significance of learning from incidents and everyday work, and highlights the importance of building the capacity to learn over rigid adherence to processes and compliance.

A key element in transitioning to PSIRF is the shift in what prompts a learning response. It recognises that a learning response has an opportunity cost – while we’re carrying out an investigation, we’re not delivering patient care or improving services. We can’t investigate all incidents, so we need to work out which ones to investigate. Traditionally, harm was used as the primary determinant for initiating investigations. PSIRF advocates moving away from this approach towards a focus on ‘learning potential.’ This shift in focus recognises that an incident’s potential for learning does not necessarily correlate with the degree of harm caused. 

Learning potential can be affected by:

• Scale and impact. Is the incident too small to learn from, or even too large? If an incident is too large, there may be political or organisational pressures that prevent honest discussion and learning. Scrutiny from stakeholders with face-saving agendas can block deep inquiry. 
• Frequency. How often does this occur? Very rare incidents may not drive effective change. If a meteorite hit an operating theatre, there may be very few lessons that are worth making to prepare for that happening in the future. Very common events can indicate systemic problems to solve.
• Generalisability. Can we apply our learning from this to other incidents and contexts? Or is it such a specific event that we’re unlikely to be able to apply learning from it? Incidents from which learnings can be applied to a wide range of practices or teams may be useful to investigate.
• Practicality of improvement. What is our ability to make changes as a result of the learning response? If an incident is outside our scope or authority, we may not be able to implement lessons from it.
• Existing improvement work. Is this covered by existing improvement work? If we’re already working on improvements but they’re not yet in place or complete, carrying out an investigation may be solving yesterday’s problem, not today’s.
• Pattern Identification. Are there similar past incidents or near misses? Does this incident represent a recurring pattern that hasn’t been addressed yet?
• Involved Processes and Systems. Which healthcare processes or systems were involved in this incident? Are these processes or systems prevalent across different areas of the healthcare organisation, or other organisations? 
• Regulatory or Legal Implications. Does this incident have potential legal implications? Are there regulatory standards or guidelines related to this incident that may need to be reviewed or addressed?
• Effect on Healthcare Team. How did this incident affect the healthcare team involved? Could there be potential learnings to support team resilience or wellbeing?
• Impact on Patient Trust and Confidence. Incidents that could significantly affect patient trust and confidence in the healthcare system often hold high learning potential.

To maximise learning, we’re looking for (as John Allspaw describes them) “Goldilocks Events”. They’re not too big, they’re not too small, they’re not too rare, they’re not too common, and we can actually use them to learn and apply improvements.

Not Just Incidents

Since the criteria for a learning response is “learning potential” – why would we restrict ourselves to only learning from things going wrong? Because we’ve changed the criteria from “harm caused”, now we can and should carry out investigations for successes too. We can learn just as much, if not more, from things going right – after all – that happens a lot more often! Studying everyday work can be a powerful tool in learning about success.

As shown, PSIRF calls for an end to RCAs, suggesting the adoption of alternatives that apply human-focused and system-oriented approaches that utilise qualitative methods, including interviews, focus groups, and observations. Practices such as empathy mapping can further enhance understanding of both practitioners’ and patients’ experiences (you can find an Empathy Map Canvas in our Healthcare Practice Playbook). Central to these methodologies is the principle of Local Rationality: the belief that people do reasonable things given their goals, knowledge, understanding of the situation and focus of attention at a particular moment. This principle allows for a more nuanced understanding of behaviour during incidents, focusing on contextual factors rather than assigning blame.

Psychological Safety

The implementation of PSIRF necessitates the development of cultures that foster psychological safety throughout an organisation, from teams to the highest layers of the healthcare hierarchy. It allows for a more comprehensive, nuanced understanding of safety incidents and a greater focus on learning and improvement. As such, I believe (and hope) that PSIRF represents a dramatic shift in the NHS’s approach to patient safety, with a potential for significant positive impact on patient care in the UK.

Healthcare doesn’t have to be the only field to benefit from this approach of course. I’m hopeful that other domains and industries such as technology or heavy industry may adapt and adopt some of the elements of PSIRF that translate across domains, particularly the acknowledgement of the essential need for a systemic foundation of psychological safety.

Thanks so much to Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England, for the invaluable input and advice that went into creating this piece about PSIRF and the changes required to transition toward it. 

To help healthcare practitioners on the PSIRF journey and to foster psychological safety, we’ve published the next in our series of psychological safety Practice Playbooks. This one focuses on healthcare, and contains the following:

1. Personal User Manual Template for clinical roles
2. Empathy Mapping Canvas
3. Local Rationality Investigations Guide
4. Learning Potential Checklist
   

Check it out, alongside our other Practice Playbooks, at the psychsafety.com toolkits page.

Psychological Safety Practice Playbooks

In addition to our “Teams and People” Practice Playbook, we now have Technology, Education and Healthcare Practice Playbooks available to download. 

Psychological safety in Healthcare:

Very relevant to PSIRF is this article from Rosanna Hunt in collaboration with Lizzy MacNamara and Taj Nathan, about the use of narratives in learning and improving patient safety. They also suggest that the new Patient Safety Incident Response Framework (PSIRF) encourages a positive change of direction towards systemic learning approaches and fostering a Just Culture, and, like myself, believe there is a lot of work to do to change the deeply embedded cultures that can inhibit everyday learning.

It is clear that not only do we need to address operational improvements to learning in healthcare systems as per the PSIRF approach, but we also need to address the causes of increasing psychological strain and burnout in the healthcare profession. The two things are interrelated and interdependent: the same underlying cultures and practices that enable to us to learn effectively from everyday work are the same that protect us from harm and burnout.

Heidi Zen creates some fantastic illustrations that often challenge conventional thinking or ways of working in healthcare, and here’s a great one about the complexity and challenges people face trying to access mental health services in the NHS.

I love this Twitter thread from Nick Smallridge, about the power of hidden incentives. If some players on a team are afraid to try new things because in doing so they expose their perceived weaknesses, and don’t want to let the team down, they will likely act only safe, comfortable ways. “Hidden incentives”, or “quiet quests” can be a great way to incentivise taking interpersonal risks (or tangible risks in an interpersonal context). I’m really interested to hear from anyone in healthcare about how “quiet quests” could be applied in practice.

Nick Seaton shared these fantastic cards on Twitter this week, as prompts to help foster a restorative Just Culture and an environment of psychological safety. I believe they are the creation of Anne Reader, Associate Director of Quality and Patient Safety at UH Bristol & Weston NHS.

If you’re in or around healthcare and would like to get in touch about anything in this week’s newsletter, please do so by emailing tom@psychsafety.com.

Public Libraries are amazing and sacred spaces. When hanging out in the local library with my daughter this week, we found this excellent work: It’s OK to Make Mistakes, with Little Brown Bear. I remembered the story that Jeff Bezos insists that his top executives read The Effective Executive by Peter Drucker, The Innovator’s Solution by Clayton Christensen, and The Goal by Eliyahu Goldratt, and I think this book should be in that list!

This week’s poem:

Don’t Give Up, by Jonah Matranga

I know I could never really know the way you’re feeling
But I’ll try
I know things or you might not be who or where you want them
And that’s fine

Just cut away the noise
Listen for that voice

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Cos we all want a world where all our life might really matter…
And if you don’t
Then quiet please so we can fix this world before it shatters
We gotta figure this out
With you making all that noise then we won’t
Cos somebody’s sick or somebody’s sad
Or they’re missing their kid or they’re missing their dad
Someone’s getting beat up just for being who they’ve been since they were born
Just for being who they’ve been since they were born
So don’t give up

Anyone who’s out here with me
Sing it to each other softly

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Anyone who’s out here with me
Sing it to each other softly

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Don’t give up
No matter what now
Don’t you stop
Don’t give up

Listen to “Don’t Give Up” by Jonah Matranga at his website. Jonah’s music has been a big part of my life for a long time, from his first band “Far”, to his work under the guise “onelinedrawing” and the band “New End Original” (an anagram of onelinedrawing). He now largely releases music and tours under his own name, and is a wonderful person as well as a talented musician.