Judy Walker: The PSIRF learning response tools survey summary report (24 July 2024)

Summary

NHS England’s’ Patient Safety Incident Response Framework (PSIRF) plan has paved the way for a significant shift in how organisations should be learning from patient safety events. Judy Walker undertook a snapshot survey in June 2024 that provides a first glance of the national picture of how PSIRF is being applied especially about the learning response tools (LRTs) that are being used. The findings are positive, with real change taking place, yet there is wide variation in application and process and a strong desire for more specific training in the skills required to use the LRTs.

Most respondents felt that the shift to PSIRF was having a positive impact on the quality of learning after patient safety events and this was particularly so for the respondents who had themselves led After Action Reviews. The data and text based responses, suggest that some organisations have only begun to implement PSIRF and use the LTRs in the past few months, whilst others are much further along the integration journey. 

Content

The survey found that After Action Review (AAR) is the most frequently used of the LRTs, followed by thematic reviews and multidisciplinary team (MDT) reviews, with some respondents reporting high levels of learning activity using these three tools. This suggests that using LRTs as well as PSII, has increased the scope of what is being learned about to include a broader range of concerns. However, the demands this has on staff time to participate in LRTs has increased along with the need for more administration of learning activities. 

One of the aims of PSIRF has been to speed up the learning process, meaning that safety could be improved, and patients informed sooner. This is happening, with 84% of learning responses taking place within 6 weeks of the event and 59% of AARs take place within 4 weeks.

There is currently widespread variation in how learning responses are arranged and who is involved in decision making about which LRT to use. Adaptation is necessary to reflect the local governance structures and to accommodate how the PSIRF implementation is being resourced, but the lack of standardisation may be a barrier to operating efficiently, especially for the ICBs and other stakeholders. It may also become a barrier to identifying and developing quality in managing learning responses. 

When exploring what is needed in the future both within their own organisations as well as outside of them, more training was the most frequently sited requirement. Support for quality assurance and effective mechanisms for collating and sharing lessons was also expressed. 

Involving patients and family members in AARs is still underdeveloped. Most respondents are being cautious about the type of involvement patients have, with the preference for informing them of the outcomes, rather than helping them participate more directly. 

The respondents have been very active in informing staff about the new PSIRF tools, hosting events, engaging with staff directly as well as by providing digital and printed materials. However, 78% of respondents when asked about how much knowledge staff had about AAR, gave a score of 4 or less suggesting that knowledge about AAR in organisations is quite limited as yet.

If you would like to see a copy of the full report or to speak to us about providing the highest standards of training for your After Action Review facilitators,  please email [email protected].