Frozen (or more importantly, in the words of Idina Menzel, "Let it go")

Let it go! Let it go! Bureaucracy and burden in incident response. Let it go!

When implementing PSIRF there is a temptation to create reporting structures around the PSIRF toolkit, which retain or introduce unnecessary bureaucracy. Why do you have to ‘let it go?’ Bureaucratic reporting structures around After Action Review (AAR) and SWARM huddles transform what are intended as empowering, free-choice and reflective team learning conversations into something they were never intended to be.

"The process will be as follows, staff report the incident on the incident reporting system. Incidents will be screened by the central patient safety team. Those incidents meeting the ‘criteria’ for an After Action Review will then be scrutinised at the Patient Safety and Risk Group meeting – which will meet weekly. The Patient Safety and Risk Group have the decision-making authority. They will notify the reporter whether the incident warrants an After Action Review."

If you are having conversations like this, it is time for a re-think.

If your incident response oversight conversations are starting with, "What should have happened and what did the staff involved do that led to the incident?" you are not letting go of the old-style ‘shoulda, woulda, coulda’ counter-factual thinking model that dominated our thinking under SIF.

Our conversations should be starting with, "Who are ‘those affected’? How are we supporting them? Have those affected shared their views on how we might best support them? How can we meet their individual needs, to ensure we provide personalised support for everyone?"

And, in relation to specific patient safety incidents, "What does our plan tell us about the potential for learning and improvement? Is the incident either a national or local safety priority? Is it a newly emerging incident which we were not aware of when we wrote our PSIRP? What (if any) ongoing improvement work is underway? What would a proportionate response look like? Given what we know so far, and what is set out in our plan, what tools in the PSIRF toolkit should we apply to learn from this incident?"

Don’t be Frozen. Abolish unnecessary bureaucratic structures and reporting. Empower and engage staff to use  the proportionate tools in the PSIRF toolkit. And that leads us onto our next movie…

Apollo 13: "Houston – we have a problem!"

Apollo 13 was the seventh crewed mission in the Apollo space programme and the third meant to land on the Moon. The craft was launched from the Kennedy Space Center on 11 April 1970, but the lunar landing was aborted after an oxygen tank in the service module failed two days into the mission. For two days, Mission Control in Houston and the crew improvised new procedures so it could support three men with sufficient oxygen to survive for four days.

Starring Tom Hanks as Jim Lovell, the commander of Apollo 13, the movie tells the story of the mission. Jim Lovell coined the term, "successful failure". He states that, to solve any problem, organisations need to ensure teams have leaders who foster good teamwork, empowering team members to use their initiative.

Leaders also need to recognise that solving a problem starts with digesting what the problem is. Leaders need to give team members space to recognise what has happened, offer a supportive steer, and give them the time and space to think creatively.

Leaders in oversight roles need to adopt this approach to support organisations and enable their PSIRF transition to become a success. When using the tools in the PSIRF toolkit, remember testing and adapting them is part of your PSIRF implementation journey.

Adopt the quality improvement mantra, "go where the will is". If you discover a PSIRF pioneer or enthusiast who is keen to use one of the PSIRF tools, empower them to do so.

And that theme of empowerment and going where the will is, segways nicely into our next movie...

Fences: Breaking down silos will enhance safety improvements

The movie Fences, starring Viola Davies and Denzel Washington, includes the quote: "Some people build fences to keep people out and other people build fences to keep people in."

PSIRF is a significant change in policy, process and behaviour. It’s an organisational development intervention that should have the full support of leaders to create new ways of working that will support organisational learning, action and cultural change. 

Some (not all) healthcare organisations have traditionally been organised so there are separate teams or functions who lead on patient safety, quality improvement, AAR/debriefing, human factors science, etc.

Collegiality and collaboration between patient safety, human factors, quality improvement and AAR/debriefing experts is essential for successfully implementing the PSIRF toolkit.

Quality improvement empowers front-line staff to innovate and lead the change: the testing, adapting, adopting, or abandoning principle and much more.

Human factors scientists are vital for understanding ‘work as done’ and for identifying strong safety actions and systems redesign that is user-centred. Human factors scientists can also provide insights into user-centred, PSIRF tool template design and can support testing the usability of PSIRF tool templates. By PSIRF tool template design, we mean how we design templates and pro formas to capture what we have learnt when applying tools in the toolkit. We talk more about this later in the blog…

AAR/debriefing experts have the skill set to create a psychological safe space for reflective learning. They will also provide sage advice that tools like AAR, if implemented in their truest sense, should be free-choice learning conversations, where creating a psychological safe space is essential.

In short, combining collective wisdom is the way forward when implementing the PSIRF toolkit and making decisions about how to report what is learnt.

Forrest Gump: "My Mama said, ‘Life was like a box of chocolates: You never know what you are going to get'".

Complex, highly adaptive systems like healthcare comprise multiple subsystems that interact in a myriad of ways. This in turn means system performance can be unpredictable. The Forrest Gump quote, "My Mama said, Life was like a box of chocolates: You never know what you are going to get," captures one of the challenges of improving patient safety in healthcare.

We cannot predict what type of patient safety incident will happen next, or when and where it will happen (despite often seeming alarmingly obvious in hindsight).

Healthcare organisations use risk registers and risk assessments to describe and quantify future patient safety risks. These tools serve a function, but they do not allow healthcare organisations and teams to foresee the next patient safety incident. In complex, adaptive systems where there are moment by moment, hour by hour changes, it is not possible to predict the patient safety incident that lurks around the next corner.

The analogies between Forrest Gump’s quote and the PSIRF toolkit don’t end there. The toolkit comprises a wide-ranging set of methods and approaches, including PSII, AAR, SWARM huddles, multidisciplinary team (MDT) review, SHARE debrief, the Horizon scanning tool, SEIPS-based observation tool, interview guidance, work system scans, interaction maps and many more. The tools are complementary; AAR and SWARM huddles support reflective learning in a psychologically safe space after an incident, the MDT tool can be applied to explore pathways, processes and/or historic incidents, and the horizon scanning tool is designed to unpack emergent patient safety issues.

Setting in stone which tool will be applied when (for example, by setting this out in your patient safety incident policy or plan) may create unanticipated side effects. First, the PSIRF philosophy is one of empowering learning. Dictating which tool should be applied when may negatively impact on staff willingness to engage. Healthcare organisations may unwittingly introduce boundaries on what they learn by always using the same tool.

Second, mixing and matching the tools enriches learning. Comparing and contrasting ‘hard data’ and soft safety intelligence gained through observations, conversations, perceptions, gains deeper insights into patient safety improvement. Having hard and fast rules like, "Tool X will be used for incident type Y; Tool A will be applied if incident type B," means that combining tools is unlikely to occur.

Another Forrest Gump-related lesson is that how a box of chocolates is packaged and presented impacts on its saleability/marketability. The same applies to the tools in the PSIRF toolkit. We see on PSIRF sharing platforms examples where root cause analysis templates have been re-branded as AAR or SWARM huddle or MDT review templates. We have also seen the (understandable) requests for PSIRF tool templates to be shared. Collaborating and sharing are integral to PSIRF. However, when sharing, stop for a moment and consider what potential negative side effects a lengthy PSIRF tool template may introduce. Poorly designed, lengthy PSIRF tool templates distract us from learning and improving. They may unwittingly create another data collection task, and/or disrupt the psychological safety of learning conversations, by creating a focus to form-filling and box-ticking. Our message is, share, pinch with pride, but do so in a discerning way whereby you stop and ask the question, "how might the design of this template impact our focus on learning and improvement?"

Choosing a tool for reviewing or finding out a little more about work as done versus work as imagined is one challenge. Is this the right tool? Will it allow you to look at the issue from all perspectives? Just because you have chosen a tool doesn’t mean ‘job done’. Sometimes a combination of tools will give you a richer, more rounded view of the problem.

For instance, combining the AAR and an observation can give you a more detailed view. With the AAR you get to ‘zoom in’ to the actual incident and find out all the contributing factors to why that specific incident happened (work as disclosed), but combining this with an observation you can then ‘zoom out’ and see what usually goes on day to day (work as observed). 

Everything. Everywhere. All at Once

Don’t ask us what the storyline of the movie, ‘Everything. Everywhere. All at Once,’ is. We don’t know. A couple of the blog’s authors attempted to watch it after it won several Oscars in 2022. We gave up. But the movie title has an important message for those leading PSIRF implementation: PSIRF is a movement. Movements take time to implement. There is no expectation your approach, PSIR plan, application of the PSIRF tools, etc., will be perfect.

Adopt the ‘all share, all learn’ philosophy. Build networks and collaborate. And remember, if, at times, you feel overwhelmed by the scale of the change, everyone else probably does too.

Back to the Future: Past, present and future safety

The Health Foundation report, The Measurement and Monitoring of Safety (Vincent, Burnett and Carthey 2013) highlighted that, predominantly, healthcare organisations focus on learning from past events (i.e., incident reports, incident investigations, claims, complaints, etc.). There is less focus on present levels of safety (i.e., is care safe today?) and even less on future safety (will care be safe in the future?).

Some of the tools in the PSIRF toolkit allow us to explore present events (e.g., observations, walk-throughs, the SEIPS work system explorer). Others support consideration of future events (e.g., the horizon scanning tool).

When implementing the PSIRF toolkit it is important to stop and consider whether your organisation is remaining entrenched in the ‘learning from the past’ zone. Effective incident response requires more than waiting for an incident to occur and then exploring ‘work as done.’

By balancing the effort across tools that generate insights into the present and future, as well as past events, your organisation will have a more holistic approach.

And our final message relates to kindness and compassion – to yourself and others on the journey to implement PSIRF...

Groundhog Day

In the film Groundhog Day, Phil, a weatherman, goes to the town of Punxsutawney for an assignment and ends up re-living the same day, over again. As the movie unfolds, Phil starts to believe he is destined to spend eternity re-living the same day.

Healthcare organisations must sense check whether they are reverting to a focus on error and compliance, losing sight of the focus on patient safety improvement. It will happen. Human beings are susceptible to stereotype takeover: routines, language and habits from the old world of SIF will creep into our PSIRF conversations and decision making.

We all need to accept that reverting back to old habits, language and being tempted to revert to or hold onto old ways of working is a natural human response to change. Be cognizant of this. Recognise it will happen. When it does inject kindness, compassion and (where appropriate) humour to steer colleagues back to the focus on improvement.

Conclusions

Finally, from us. Seven movies, seven questions:

1. Frozen: Let it go! If your organisation put its PSIRF processes under a microscope, would you still see complex, bureaucratic reporting, triage and/or decision-making requirements? In short, can your organisation demonstrate it has let the unnecessary bureaucracy go?
2. Apollo 13: Houston we have a problem! Are you adopting the quality improvement mantra, ‘go where the will is’ and empowering PSIRF pioneers and enthusiasts to use and adapt the tools?
3. Fences: "Some people build fences to keep people out and other people build fences to keep people in." The benefits PSIRF brings will be difficult to achieve by patient safety leaders alone. Does your organisation have patient safety teams, human factors scientists, quality improvement teams and AAR/debriefing facilitators, and other specialists working as 'one team’ to support PSIRF implementation? If no, how might you overcome barriers that prevent this?
4. Forrest Gump: "Life is like a box of chocolates." Have you stopped and considered how the design of your PSIRF tool templates might impact on the psychological safety of the conversation healthcare teams have?
5. Back to the Future: Past, present and future events: ‘What are your plans to ensure your organisation learns from present and future events, as well as past events?
6. Everything. Everywhere. All at Once: "Every rejection, every disappointment has led you here to this moment". Are you rushing to get PSIRF ‘done’ or are you on a journey?
7. Groundhog Day: Do you ever have déjà vu? How are you and others responding when conversations drift back into the old way of focusing on blaming staff; the error, non-compliance or when the ‘shoulda, woulda, coulda’ conversation re-emerges?

The NHS and healthcare love acronyms. Indeed, if you have an interest in patient safety (and let’s face it, who doesn’t?) acronyms are everywhere. We have PSIIs, LFPSE, PSPs, SIF, AAR, HSIB, GIRFT, CIEHF, TRIM, SEIPS and PSIRF, to name just a few!

Focusing on that last five letter acronym: PSIRF – which stands for the Patient Safety Incident Response Framework. Five words, thirty-eight letters. Jargon. However, PSIRF is undeniably different and represents a sea of change in patient safety, heralding a new era of how organisations will be expected to keep patients safe and respond to incidents. The accompanying literature tells us that PSIRF is ground-breaking and that it represents, arguably, the greatest change in patient safety culture since the inception of the NHS in 1948.

Obviously given its importance, PSIRF is not something that has sprung up overnight. In 2018, all NHS organisations were asked to take part in a far-reaching consultation looking at patient safety. The researchers, analysts and experts crunched the data and assessed the feedback, culminating in the publication of the NHS Patient Safety Strategy in 2019. Before PSIRF was rolled out to the NHS nationally, the NHS decided to test the new framework out on around 20 early adopter sites. This ‘testing phase’ helped inform and shape the future of PSIRF before the formal documents were published in August 2022. Since then, all NHS Trusts have been working to embed and implement PSIRF by the end of 2023. This is a challenging timeframe, with lots to be done. To meet the challenge, Trusts have created new roles and new posts and invested significantly in PSIRF.

This brings us onto the graphic that we created. While many of us had waited patiently during 2022 for the PSIRF publications, what immediately became clear in August 2022 was the sheer scale of PSIRF. On 16 August 2022, around 20 PSIRF documents landed totalling well over 400 pages of, often quite technical, literature. Although this information was backed-up with useful quotes and soundbites from NHS leaders and a few insightful four-minute films, we felt there was a need to create a simple eye-catching document that simply explained PSIRF.

Work on the graphic commenced almost as soon as the PSIRF documents dropped in August 2022. We read as much of the formal literature as we could in August, looked at articles from key leaders and a range of organisations, scanned Twitter and spoke to our friends and colleagues working in the field to see what themes stood out for them. Prior to creating the poster, we had received very positive feedback on a couple of similar graphics we had created for the clinical audit community so we determined that we should keep the format the same.

In the first instance, nine themes stood out and we asked our illustrator, Amy, to create simple and memorable images. Once the poster had been checked we uploaded this onto Twitter and likes immediately started to rack up. As with any work we do, we encouraged feedback and within four weeks it was clear that we should extend the poster to incorporate a total of twelve images not nine, so we added ‘supportive oversight’, ‘expert investigators’ and ‘psychological safety’.

Simultaneously, while re-designing the poster in Autumn 2022, we ran and attended several online events where it became evident to us that many healthcare staff outside of patient safety and risk teams lacked a basic understanding of PSIRF. For PSIRF to reach its full potential ALL staff working in healthcare must understand the fundamentals of the framework and it has been pleasing to see that the feedback on the poster has been positive, with many telling us that the graphic helped them understand and want to find out more about PSIRF.

Overall feedback has been positive – we have been surprised and delighted that Trusts have asked to use or adapt the original poster. We did encounter one co-ordinated series of tweets in January 2023 implying that we had taken the important topic of patient safety and turned it into a cartoon! We take all feedback seriously but after consulting with key leaders we were encouraged to retain the poster in its current format.

As PSIRF celebrates its first birthday in August 2023, we are considering making a few tweaks to the original design. Our aim was to create an eye-catching and easy to understand poster explaining what PSIRF represents. We know how busy healthcare staff are and that most have limited time at their disposal, even when it comes to learning about major initiatives such as PSIRF. Hopefully the poster has helped and sparked further interest.

Stephen and Tracy are happy for you to download and share the poster within your organisation as long as it is not amended. Also, keep a look out for version two in the Autumn.