Patient Safety Incident Response Framework Policy

This document should be read in conjunction with the Trust Patient Safety Incident Response PLAN_1.0

1 INTRODUCTION

This policy supports the best practice guidance set out in the NHS England Patient Safety Incident Response Framework (PSIRF) and explains how Buckinghamshire Healthcare NHS Trust (the Trust) will approach the development and maintenance of effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

2 PURPOSE OF POLICY

The PSIRF advocates a coordinated and data-driven response to patient safety incidents. It embeds patient safety incident responses within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.

This policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF as per the PSIRF National policy which can be found here Key Aims of PSIRF

These aims align to our existing Trust values which are:

Collaborate together as a team
Aspire to be the best
Respect everyone, valuing each person as an individual
Enable people to take responsibility

This document should be read alongside the Trust’s Patient Safety Incident Response Plan (PSIRP).

3 SCOPE OF POLICY

This policy relates to all colleagues working within the Trust and is specific to patient safety incident responses conducted solely for the purpose of learning and improvement across the Trust.

Responses under this policy follow a systems-based approach. This recognises that patient safety is an emergent property of the healthcare system: that is, safety is provided by complex interactions among several components of the healthcare system and not from a single component. This approach is specific to patient safety incident responses conducted solely for the purpose of learning and improvement across all BHT services as identified in the Patient Safety Incident Response Plan and the clinical services listed on the Trust’s website.

Learning responses do not take a ‘person-focused’ approach where the actions or inactions of people, or ‘human error,’ are stated as the cause of an incident. Where other processes exist with a remit of determining liability or to apportion blame, or cause of death, their principal aims differ from a patient safety learning response. Such processes as those listed below are therefore outside of the scope of this policy:

Claims handling,
Human resources investigations into employment concerns,
Professional standards investigations,
Information governance concerns
Estates and facilities concern
Financial investigations and audits
Safeguarding concerns
Coronial inquests and criminal investigations
Complaints (except where a significant patient safety concern is highlighted)

For clarity, the Trust considers these processes as separate from any patient safety incident response. Information from a patient safety incident response process can be shared with those leading other types of responses, but other processes should not influence the remit of a patient safety incident response.

4 ROLES AND RESPONSIBILITIES

4.1 Principles of oversight

Working under PSIRF, organisations are advised to design oversight systems to allow an organisation to demonstrate improvement rather than compliance with centrally mandated measures.

The Trust will work collaboratively with BOB ICB to ensure we have effective oversight and improvement of patient safety across our systems and to support where appropriate cross-organisational learning. This will involve participation in identified relevant forums such as Regional Patient Safety & Improvement Forum, regular PSIRF reviews, peer reviews and educational events.

4.2 Ensuring that PSIRF is central to overarching safety governance arrangements

The Trust Board will receive assurance regarding the implementation of PSIRF and associated standards via existing reporting mechanisms such as the Patient Safety Board, Patient Experience Board, Clinical Effectiveness Board, Care Group Performance Reviews and Trust sub-board Quality & Clinical Governance Committee.

The Trust will source necessary training such as the Patient Safety Syllabus (Health Education England) and other patient safety training options as appropriate to the roles and responsibilities of its colleagues in supporting an effective organisational learning response to incidents.

Updates will be made to this policy and associated PSIRP as part of regular oversight. A review of this policy and associated PSIRP should be undertaken at least every 3 years.

4.3 Quality assuring learning response outputs

The Trust will implement a Patient Safety Incident Panel (PSIP) to ensure that PSIIs and learning responses are conducted to the highest standards and to support the executive sign off process and ensure that learning is shared trust wide across all care groups, and safety improvement work is adequately directed.

The PSIP will also take oversight and provide executive sign off for all PSRs unrelated to deaths.

5 RESPONSIBILITIES

Chief Executive Officer

The CEO is responsible for ensuring that the appropriate governance arrangements are in place to support openness between healthcare professionals and patients and/or their carers, colleagues, and visitors.

Chief Operating Officer

The post holder is responsible to the Chief Executive Officer in ensuring that governance arrangements are in place and risks are managed within the Trust.

Chief Nurse Officer

Designated Executive Director for PSIRF. The Chief Nurse will oversee the development, review, and approval of the Trust’s policy and PSIRP ensuring that they meet the expectations set out in the national patient safety incident response standards. The policy and PSIRP will promote the restorative just working culture that the Trust aspires to.

Chief Medical Officer

Has the lead responsibility for the Learning from Deaths process.

Deputy Chief Nurse

Has delegated responsibility from the Chief Nurse for enacting the development, review, and approval of the Trust’s policy and PSIRP ensuring that they meet the expectations set out in the national patient safety incident response standards.

Care Group Directors, and other senior Managers (including senior Governance roles in Care Groups): Have responsibility for ensuring Care Group commitment to implement the policy as well as for putting effective governance, systems, and processes in place to enable successful implementation.

Patient Safety Specialists and Patient Safety Manager: Have responsibility for providing patient safety expertise and independence to support the implementation of the policy, as well as working alongside operational colleagues to develop effective governance, systems, and processes for successful implementation of the policy.

Managers and Service Leads: Are responsible for ensuring their services and teams are provided with the right conditions to support them to engage in and practically implement the policy

Patient Safety Investigators: Have responsibility for providing patient safety expertise and independence to support the investigation of Patient Safety Incidents as well as working alongside operational colleagues to complete robust Safety Improvement action plans and monitor and update these as required.

Family Liaison Officer: Have responsibility for leading on engaging with and involving those affected by a patient safety incident including supporting with the completion of Duty of Candour requirements.

All colleagues: Have a responsibility to behave in a way which supports an effective patient safety culture.