Event ~ Helping leaders to use insights from learning from deaths to implement the new Patient Safety Incident Response Framework

Helping leaders to use insights from learning from deaths to implement the new Patient Safety Incident Response Framework

As services and systems prepare for the implementation of the Patient Safety Incident Response Framework (PSIRF), there are signicant opportunities to improve the quality, safety governance and impact of learning outputs from investigations. If implemented effectively, the PSIRF will offer new data, insight and greater understanding of safety for local and national leaders to take action to improve future outcomes. There will also be a greater focus on collaboration across multiple agencies and providers, supported by the ICBs, that will help to develop, maintain and review incidents and strengthen safety management systems. However, in the last decade, we know several national programmes have set, driven or reviewed the NHS approach to learning from deaths and found issues with consistency, learning and impact following unexpected or preventable deaths. The challenge for all is how we make sure the priorities set in implementing the PSIRF are directly informed and build upon existing learning from deaths case reviews, investigations and data.

Niche have over 30 years of experience working with our clients to investigate safety incidents and supporting leaders when deaths in care occur. We have completed large scale, complex enquiries and offered ongoing support for assurance and analytics that help improve safety cultures.

The session will share insights from our work reviewing individual or multiple unexpected deaths, and working with leaders to find tailored and responsive solutions based on needs of their patients and families, services and systems involved. This includes helping support relationships and information needed by coroners, medical examiners or regulators for individual responses or across system mortality and safety governance systems.

Our teams have significant experience in extending our work beyond a team and provider, instead looking across human factors, systems and national pathways and policies to understand issues and respond to specific challenges. We have worked with multiple organisations to provide insights and supported reflections on the methods, cultures and strategies that they need to put in place to offer strong safety leadership, cultures and use learning from deaths to improve health care across the NHS and wider system.

Key Subjects

During the session we will provide learning from our:

Investigations – Niche have completed hundreds of complex investigations including individual or multiple deaths in care. This has included assessing the quality of internal investigations and considering multi-agency responses and identifying actionable, credible recommendations for improvement.
System-wide mortality reviews– Working across systems and between partners to understand key learning from case reviews using a variety of process or activity data with multiple measures. These support the development of collaborative solutions that strengthen insight and improvement areas for leaders and organisations.
Mortality governance and assurance reviews – Working with boards to review the governance in place, identify improvements that are targeted to individual services or across areas of risk and help develop leaders to confidently assess priorities, maximise learning and seek service improvement based on patient safety issues.
Supporting safety cultures – Helping support local or system implementation of national policy including Learning from Deaths and identifying opportunities for improvement and impact for people using services, staff and families.

The session will be structured against key themes within the PSIRF, helping leaders to identify what they can do to help prepare their organisation and teams by using their existing mortality processes to bring insight to implementing the PSIRF

Learning potential: What factors can we apply based on learning from previous investigations following death, actionable recommendations and impact to be able to determine learning potential at a local, system or national level? What learning is offered by previous complex investigations following deaths in care that will help leaders identify priorities?
System and family engagement: How can PSIRF ensure that system providers and families are engaged and how can this be achieved?
Assurance: Effective safety leadership and systems take time to develop and need clear priorities tailored to organisations, how can our experience help you to understand the capacity needed or identify ways to maximise improvements during implementation of the PSIRF?