The launch of HSSIB and its priorities for the future: a recent discussion at the Patient Safety Management Network

Summary

This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB).

The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network.

Content

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings. It initially started its life in 2017 as the Healthcare Safety Investigations Branch (HSIB), subsequently undergoing a period of transformation following new legislation in the Health and Care Act 2022 to become HSSIB on the 1 October 2023.[1]

Dr Ted Baker joins HSSIB as its first Chair. He was previously Chief Inspector of Hospitals at the Care Quality Commission and prior to this spent most of his career working in clinical practice for 35 years.

Dr Baker welcomed the invitation to the PSMN and commended the value of the forum both for its members and for the wider healthcare community.

Role and duties of HSSIB

Opening the meeting, Dr Ted Baker set out his background prior to becoming Chair of HSSIB and talked about the origins of the organisation. He explained that this was established as an arm’s length body of the Department of Health and Social Care to:

• Carry out independent investigations in health services.
• Not to apportion blame or liability.
• Focus on system-level (policy and regulatory) change.
• Professionalise the patient safety investigator role.

He noted that HSSIB will conduct investigations in what is commonly referred as a ‘safe space’ to ensure people feel able to speak up about safety concerns. This prohibits, on a legal basis, the unauthorised disclosure of protected material and applies to all HSSIB employees and anyone they provide information with as part of an investigation.

Approach to investigations

Dr Baker advised that the areas of investigation that HSSIB will focus on will be subject to a forthcoming strategic review to form their initial priorities. However, before this takes place, he highlighted that there are already several factors that influence how they approach investigations. This included the need to avoid incidents where their work would simply replicate already effective local investigations, and to focus on those cases that are likely to have widespread implications where they believe their approach can add value.

He outlined four key aspects of the HSSIB approach to investigations:

1. Wide-ranging expertise from safety-critical industries.
2. Multidisciplinary and inclusive teams; patient and family involvement.
3. Focus on learning not blame to reduce risk of harm.
4. Transparent and collaborative to support learning.

He outlined that HSSIB would be consulting widely on the criteria for investigation, and that he would welcomes input from the PSMN and its members.

Safety Management Systems

Dr Baker went on to speak about the first investigation report formally published by HSSIB, which considers the potential application of Safety Management Systems (SMSs) as an approach to managing safety in healthcare.[2]

In this report, HSSIB identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. He emphasised the importance of different parts of the system working more collaboratively to achieve this and showed a brief video explaining more about this, which can be viewed below.

Network discussion

Discussing potential themes and areas that HSSIB could consider as part of its forthcoming strategic review, the following points were made by Network members:

• Importance of considering how the themes that emerge from individual organisation’s Patient Safety Incident Framework (PSIRF) plans may help inform HSSIB’s future priorities, particularly where these are not issues specific to a locality. Dr Baker emphasised that PSIRF is a significant opportunity for organisations, and there will be significant value from the insights gained in learning responses.
• A possible future area/theme to investigate may be why organisations struggle to collaborate with each other on patient safety issues, connected with the need for a wider SMS.
• Potential to look in detail at learning from near misses.
• Considering IT risks and their impact on patient safety.
• Looking at how resources are allocated in regard to safety. Particularly in cases where there are new safety innovations and initiatives that could be implemented, potentially saving lives, but are not prioritised.
• Procurement and its impact on patient safety. How findings and recommendations from patient safety reports actually translate into change, a key issue highlighted in Patient Safety Learning’s report Mind the implementation gap.

There were also some issues raised by Network members about HSSIB’s role more broadly, including:

• Whether the scope of HSSIB investigations would extend into social care. Dr Baker noted that while their role is explicitly focused on healthcare, it may be that there are issues regarding health care services that fall within a social setting that need future investigation.
• How HSSIB will approach patient engagement, both working with patients directly and also how they take on board the wider patient/public view of what they should be prioritising.
• A question about the oversight arrangements for HSSIB, with Dr Baker noting that this is provided by Parliament.
• Discussion around the role of leadership in improving patient safety and what more needs to be done to ensure this is a core purpose for organisations.
• That HSSIB is supporting an international network of patient safety organisations from 17 different countries for shared learning.

How to get involved in the Patient Safety Management Network

Do you work in patient safety and are interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email support@PSLhub.org. And if you would like to discuss setting up other networks, we’d love to hear from you and support you.

References 

• HSSIB, HSIB legacy, Last Accessed 29 October 2023.
• HSSIB, Safety management systems: an introduction for healthcare, 18 October 2023.