Is the NHS ready for PSIRF? A blog by Chris Elston

Summary

We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce.

Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past.

There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF). 

Content

In my opinion, PSIRF is one of the biggest changes in patient safety that we have seen in healthcare since the NHS was introduced in Britain.

The historical position has been that the last person to touch a patient or the last process that the patient underwent was the cause of the patient safety incident. The learning has often been focussed on the person: telling them to be more careful, referring them to policies and guidelines. Occasionally, there will be an attempt to make the system safer, but often this is an introduction of a checklist or some statutory training.

The problem with these approaches is that only one person changes their practice and, in several months, that person may have rotated to a new placement or secured a new role, meaning that the learning from the incident disappears with them!

So PSIRF has introduced systems thinking to the NHS. This is where several different factors are examined for their influence on the way that people work: more commonly referred to as ergonomics or human factors.

Every day at work we all make a series of transactions, probably more so in healthcare. We have many different priorities and can flip from a routine situation to an emergency in the space of a few seconds, and back again. There are many different activities that need to be co-ordinated from so many different teams and there are pressures we face daily, not least the well reported industrial actions, poor staffing levels, the recruitment/retention issues and the working conditions.

So why would I think that Trusts and the wider NHS in England are not ready for PSIRF?

We are now being instructed by NHS England to look at the wider context of any patient safety incident. This means looking at the system that we work in. Basically, the NHS is beginning to modernise its approach to patient safety. It has seen the progress that has been made in other industries and has found itself stagnating at the same time as seeing so many scandals enter the press and the public’s thoughts. Many of the scandals repeat similar themes. This shows that the NHS does not learn lessons but repeats the historical mistakes and errors.

So what does looking at he wider context actually mean? A framework has been suggested to Trusts to use, this is the Safety Engineering Initiative for Patient Safety (SEIPS). This is a framework to give areas of interaction that should be looked at. It places the person at the centre of the work system but then shows how various other entities interact with the person. All of which then impacts on the processes and subsequently the outcomes.

What this does is show that the often reported 'blame culture' of the NHS does not understand the complexity of the system. In fact, using SEIPS would suggest that most patient safety incidents are a culmination of factors and events that end with an outcome, either favourable or not.

This means that the executive boards are going to have to pay attention to what is being said in the patient safety incident investigations, and in the learning responses from those patient safety incidents that don’t meet the criteria of a patient safety incident investigation.

For instance, if we look at a drug error, how many times have people asked what is the experience level on the ward? Is the patient being looked after on a specialist ward with staff who have experience in this area or are they an outlier from a specialist ward to a different specialism–for example, a gastro patient on a vascular ward?

A series of transactions

Another factor that needs to be considered is that the work healthcare professionals do is subject to a series of transactions. The individual practitioner must weigh up many different, often competing priorities to achieve their workload. For example, in the emergency department does the observations of a patient that has been in the department for several hours get completed or does the incoming admission from the ambulance service take priority? One has a measurable target (15 minutes to turn the ambulance around), the other doesn’t. This is a good example of internal and external factors influencing decision making.

We can even take the view further afield and look at the interfaces between the GP practice and the specialist service of the acute Trust. This could lead to factors outside the control of the Trust contributing, such as the expectation that GPs will follow up emergency department attendances with regular bloods but receive discharge summaries too late for the follow up, or how the GP is waiting for extended periods on the phone to make a referral which has an impact on their remaining workload.

These processes happen hundreds of times in a shift and often there is no spare staff to do the other process; for instance, in the above example, the observations of the patient that had been in the department for several hours. So the admission is completed and then a patient develops chest pain and needs an ECG, again, the observations are delayed and there is no spare staff to assist. This is not an unexpected event but entirely predictable but staffing levels do not allow for this.

What is the role of the executive board?

So if we are identifying those factors that need to be addressed in the examples above – lack of experience, lack of knowledge, outliers, staffing levels – what does the executive board do? The solutions and ability to mitigate the risks are not wholly within their ability to give. So where does the message go? To the Integrated Care Board (ICB), NHS England or to the Department of Health and Social Care (DHSC)? How can that message be passed up to those higher echelons? There does not seem to be a channel for those communications.

For those events that do not meet the threshold for a patient safety incident investigation and require a local learning response, how is that to be achieved? We are asking those over-worked, under-staffed clinical areas to release a member of staff (often someone senior) to complete the
local learning response. Although there are new tools available to use, many of which will streamline the process of the investigation and mean it is quicker and easier to identify the lessons and frailties in the system, is this an example of another transaction as described above? Does the clinical area release a senior member of staff to complete the learning response and pay bank or agency staff to cover, or do they postpone the learning response? Which often leads to superficial investigation and nothing being learnt or changed – an often cited reason why people do not report patient safety incidents. The Sword of Damocles hangs over our heads every day!

I wonder how many executive bodies are prepared to feedback to NHS England and DHSC that the current mandate to operate at greater than 100% and to reduce a backlog on the waiting list is possibly contributing to the safety incidents, alongside fatigue and the repetitive nature of tasks? Or the lack of beds as we maintain greater than 100% occupancy every day but are expected to maintain a resilience to a major incident, or the increased pressure often attributed to winter but experienced all year round now.

The positives

So this blog seems quite negative but there are some positives to this. Although I don’t think the NHS is mature enough at the moment to adopt PSIRF, there are too many documented cases of risk being identified and not actioned. There is a groundswell of opinion that something needs to change. We know that there is a retention and recruitment issue and in my opinion PSIRF gives us an opportunity to address this.

I think morale would be improved if the workforce feel that their opinion is valued and acted upon – this is very much an avenue that PSIRF can improve. The need to understand the normal and the excellent to influence every day, means that staff can be involved to improve their own areas. Staff will be engaged and proud to tell people where they work, students will have a great placement with motivated and energetic staff, leading them to apply for jobs.

The use of an appreciative style inquiry could lead to unobserved opportunities to be suggested to managers and senior staff. This in turn can lead to greater collaboration between wards, teams, care groups, divisions, Trusts and regions. This could lead to a rapid transfer of ideas across the country.

Ultimately, if we can change the mindset and the culture to one of honesty, transparency and looking for what the data is telling us, then our patients will receive safer and possibly more effective care. A win-win for everyone.

The words of President James Garfield seem particularly apt for healthcare at the moment:

“Most human organizations that fall short of their goals do not do so because of stupidity or faulty doctrines, but because of internal decay and rigidification. They grow stiff in the joints. They get in a rut. They go to seed.” President James Garfield.

I take this phrase to mean that we need to keep trying new, innovating things and, using a military phrase, 'remain rigidly flexible' to adapt, improvise and overcome all the challenges that we face.

I am committed to striving for improved patient safety by understanding the work that we currently do and looking at how the different entities of the system interact. Although I am sure PSIRF is a step in the right direction, I do not think it is the complete journey. This will be a long process, introducing new tools and, more importantly, changing the mindset and the culture of a huge behemoth of an industry.

Let's do this!

Patient Safety Education Network

Chris chairs the Patient Safety Education Network. The network is open to those who teach any element of patient safety or provide learning from patient safety incidents. The network is hosted on the hub. You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Education Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email support@PSLhub.org.

Read Chris's blog about the Patient Safety Education Network here.

About the Author

Chris joined the Royal Navy as a medical assistant in the submarine fleet, later serving on HMS Dumbarton Castle as the only medically trained member of the ship’s company. Developing a passion for teaching, Chris became an instructor on the medical assistant course. He transferred to the Queen Alexandra’s Naval Nursing Service and specialised in emergency care with two deployments to Afghanistan with the Royal Marines. Chris returned to the education field and completed his PGCE while acting as an instructor to medics of the Royal Navy, British Army and Royal Air Force.

Chris left the Royal Navy and joined the NHS as a charge nurse in an emergency department before moving into a governance and safety role as the IV devices nurse, developing his interest in human factors and safety. He completed a PG Dip in Applied Ergonomics and Human Factors before finding his current role as a patient education lead at University Hospital Southampton NHS Foundation Trust, which combines his passion for education and desire to improve patient safety.