Oversight Training - A Systems Approach to Learning from Patient Safety Incidents

All patient safety incident response oversight is led/conducted by those with at least two days’ formal training and skills development in learning from patient safety incidents and one day training in oversight of learning from
patient safety incidents.

When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”
To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations).

Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control.

It is the PSIRF executive lead’s responsibility to ensure:

Patient safety incident reporting and response data, learning response findings, safety actions, safety improvement plans, and progress are discussed at the board or leadership team’s relevant sub-committee(s)
Roles, training, processes, accountabilities, and responsibilities of staff are in place to support an effective organisational response to incidents.

The PSIRF executive lead should be responsible for reviewing PSII reports in line with the patient safety incident response standards and signing it off as finalised- Patient safety incident response standards

Competencies for individuals in oversight roles

All staff with oversight roles can:
Be inquisitive with sensitivity (that is, know how and when to ask the right questions to gain insight about patient safety improvement).
Apply human factors and systems thinking principles.
Obtain (eg through conversations) and assess both qualitative and quantitative information from a wide range of sources. Constructively challenge the strength and feasibility of safety actions to improve underlying system issues.
Recognise when safety actions following a patient safety incident response do not take a system-based approach (eg inappropriate focus on revising policies without understanding ‘work as done’ or self-reflection instead of
reviewing wider system influences).