A Patient Safety Symposium: Learning together to apply PSIRF mindset and methods

Summary

On Friday 27 September 2024, Patient Safety Learning held its first Patient Safety Symposium, organised with the Patient Safety Management Network and Patient Safety Education Network. This blog provides an overview of the event, which focused on the application of Patient Safety Incident Response Framework (PSIRF) tools and methods. 

Content

Background

First introduced in Autumn 2023, PSRIF is the new NHS approach to investigating patient safety incidents. At the core of this is the promotion of systems-based approaches for learning from incidents rather than methods that assume simple, linear identification of a single cause.

If implemented effectively, these approaches can help us gain a clearer understanding of the causal factors of harm and lead to safety improvements. However, they also represent a complex innovation in the NHS’s approach to incident investigation, requiring appropriate training and support for those implementing them.

How to use systems-based approaches to investigations promoted by PSIRF are regular topics of discussion at two of the biggest peer-support networks hosted by the hub:

• Patient Safety Management Network (PSMN) – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members. 
• Patient Safety Education Network (PSEN) – a peer network for those in patient safety education and training roles with over 450 members.

These networks provide a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. A recurring theme that often emerges from these discussions is an appetite for more practical opportunities to learn about these new systems-based approaches to investigation.

Planning the symposium

Building on conversations in the Networks, we began planning earlier this year for a new event focused on implementing PSIRF tools and methods. Patient Safety Learning, working with Claire Cox (Chair of the PSMN), Chris Elston (Chair of the PSEN) began planning a symposium that would:

• Allow members of the Networks from different parts of the country, in different health settings, both inside and outside the NHS, to explore these issues in person.
• Help to increase understanding and discover the practical application of two of these approaches: Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps.
• Help assess the value of case study based interactive training and the potential for future symposiums.

Helping to bring this event to life, the medical technology company BD kindly agreed to host this at their Safety and Innovation Hub in Winnersh, Berkshire. This enabled us to hold the event for free, with members of the PSMN and PSEN invited to attend.

Kicking off the day

The event was opened with a short set of introductions by:

• Helen Hughes – Chief Executive of Patient Safety Learning
• Tracey Herlihey – Deputy Director of Patient Safety (Digital) at NHS England
• Claire Cox – Chair of the Patient Safety Management Network

Tracey Herlihey, previously Head of Patient Safety Incident Response Policy at NHS England when PSIRF was introduced, reflected on how the framework had evolved over the past couple of years. She noted positive signs that PSIRF’s introduction had enabled people in different roles to start to talk more openly about patient safety incidents. This is particularly important as different roles can bring different perspectives on how to use PSIRF tools, allowing us to learn from each other. She also emphasised the real power and value of events such as this symposium, where people can be brought together to discuss how best to make PSIRF work for patient safety improvement.

Before going into the day, all attendees were asked to follow a simple set of rules, based on how the PSMN and PSEN operate:

• Speak in plain English, no acronyms.
• Introduce yourself by your name and your place of work – no job titles, a flattened hierarchy where all voices are valued.
• Provide a safe space to ask questions/peer support.
• Feel free to network, make connections and steal ideas.

These introductions were followed by a short icebreaking activity, before attendees headed into their first workshop of the day.

Workshop 1: AcciMaps

The first workshop began with a session on the history and principles of AcciMaps from Professor Mark Sujan. Mark is a Chartered Ergonomist and Human Factors specialist and has worked in patient safety and other safety critical industries for over 25 years. He is also Senior Science Investigation Educator at the Health Services Safety Investigations Body.

Accimaps, or Accident Mapping, is a tool initially developed by Jens Rasmussen. Applied in patient safety, it involves creating a graphical presentation of factors within a system that contribute to the occurrence of a patient safety incident. These factors are arranged into a series of levels representing different parts of the system that the event took place in:

1. Government policy and budgeting.
2. Regulatory bodies and associations.
3. Local area government planning and budgeting.
4. Company planning.
5. Physical processes and actor activities.
6. Equipment and surroundings.

Mark’s key reflection that resonated with many symposium participants was of the value of a different mindset in incident investigation, not just about the application of the tools such as Accimaps.

Following Mark’s insightful and informative presentation, attendees were split into groups at tables and provided with a scenario of a patient safety incident that needed to be investigated. Though fictional, this was drawn from aspects of previous real-life cases. Each table was asked to consider the issues and produced their own AcciMap.

Reflecting on this exercise, some key thoughts from attendees included:

• This approach could help to gain a viewpoint of the ‘bigger picture’ in which an incident occurs; it’s most definitely a reflection of the system in which an incident occurs and not just looking at the ‘people factors.’
• There were some significant differences in the causal factors identified by different groups, reflecting the mix of expertise and roles in the room. This reinforced the value of a team-based approach to applying Accimaps and the value of educational events, working through simulations to inform learning and application.
• The value of using debriefing techniques in healthcare alongside this, and building this into the wider organisational culture—not just when incidents occur.
• Also taking an appreciative inquiry approach, looking for what went well within the scenario.
• Other systems-based approaches that could work alongside this, such as After Action Reviews and Swarm Huddles.

Lunch break and escape room

During the lunch break, attendees had the opportunity to participate in two patient safety ‘escape rooms’ in the BD Safety and Innovation Centre simulation suite, set up as a hazard identification exercise. Participants assessed the hazards in a community based setting and another in a hospital environment. This was a fun approach to a serious set of issues that generated much discussion.

There was also an opportunity for patients to purchase a copy of a new book, Patient Safety: Emerging Applications of Safety Science, from Class Professional Publishing. This book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, including members of the PSMN and PSEN who were in attendance at the symposium.

Workshop 2: SEIPS

The afternoon workshop kicked off with an introduction to SEIPS by Nikki Fountain, Network member and Business Manager to the Chief Medical Officer at Great Ormond Street Hospital for Children NHS Foundation Trust. The symposium attendees were asked to carry out a SEIPS analysis after being shown a short video that illustrated a simulation of a routine and normal work scenario—taking blood in an ill-suited work environment.

SEIPS is a framework for understanding outcomes within complex socio-technical systems. It is a conceptual tool that depicts the interactions between three key components: work system, process and outcomes. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts you to look for interactions rather than simple linear cause and effect relationships.

Following Nikki’s introduction, attendees were split into groups at tables again and asked to carry out a SEIPS analysis of the scenario they had watched. Chris, Claire and Helen enjoyed creating the video although no acting awards are likely to be awarded!

Reflecting on this exercise, some key thoughts from attendees included:

• While there were elements of good teamwork in the scenario, there was a notable trend of staff not recognising other colleagues becoming gradually overwhelmed.
• While nothing went ‘wrong’ in this scenario, the patient received the treatment required, observation showed that both the patient and staff member had a negative experience and there were potential risks in handling and supply of samples that could lead to problems.
• There were areas where there may be obvious quick fixes to put in place, but the challenge would be to make these sustainable under normal work pressures.
• There was a conversation about how patients could be involved in SEIPS style analysis, and how this would work in practice.
• Some reflections of SEIPS being used individually at trusts, when this is perhaps more effective as a group tool.

End of day reflections

Concluding the day, attendees reconvened in the main meeting space and shared reflections on the event, which included the following points:

• Great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning.
• You don’t need to wait for a safety incident to use these tools for safety improvement.
• Everyone can make a valuable contribution to patient safety discussions, both those in clinical and non-clinical roles. Different types of expertise are greater than the sum of the parts when pooled together.
• Appetite to see more system leaders/decision makers in the room for these type of events to underline the commitment to transforming how we approach incident investigation in trusts.

Following the event we asked attendees to complete a short feedback form offering their reflections on the day. When asked what was their key takeaway learning, answers included:

“The timeliness of utilisation of various tools, and the need to be aware of perceptions affecting the outputs from using the tools and the need for a multi-disciplinary approach.”

“Mindset over method. Diversifying thinking. Accimapping for improvement rather than for incidents.”

“Networking empowers. Great to hear that other organisations are struggling with similar issues, that proves that we are on a journey to change the safety culture.”

“We're all in the same boat, it was great to hear how other organisations are embedding some of the learning tools.”

“Thinking about the different tools being part of your learning response toolkit and that it's not either/or...you may want to use more than one tool and the same incident - different ways of looking at what happens and there is no one way or right way.”

We also asked attendees if there were any PSIRF tools or approaches they would be more likely to implement at their organisation after attending this event. Responses included both Accimaps and SEIPs, the subject of both workshops, but also SWARM huddles which were discussed at several points across the day.

Other general reflections from attendees included:

“Really useful to have a space and down time for reflection, thinking and learning with and from peers. Great that the schedule was generous with time and only had 2 sessions and lengthy breaks to enable this.”

“It was truly wonderful, so well thought out so engaging. Attending on my own and having table already mapped out was brilliant. The interaction. The lunchtime escape rooms and the ice breaker. Such a great networking opportunity. The best meeting in this field ever.”

“Love the honesty in the room and sharing.”

“It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current PSII reports and provided a critical friend approach to each other.”

“A wonderful opportunity to network and learn from each other, really well considered agenda, and fabulous presenting. Felt like a family as we know each other virtually. The informal 'ness' of the setting allowed us to really network and get to discuss key issues we face. I really enjoyed listening and learning from the experts.”

How to join a hub network

You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. 

The founders of each group have set the following criteria for who can join:

• Patient Safety Management Network – UK hub members in a health or care service provider organisation who have an active patient safety role.
• National NatSSIP Network – UK hub members involved in or leading NatSSIP/LocSSIP work in their organisation.
• Patient Safety Partner Network – UK hub members in a health or care service provider organisation who volunteer officially as a Patient Safety Partner. 
• Patient Safety Education Network – UK hub members involved in patient safety education/ training in their organisations. The community excludes commercial training providers.
• Patient Safety Paediatric Leaders Network – UK hub members who are strategic-level decision makers in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. You should have a role that reports to a member of the Executive and have been nominated by your CMO or CNO, and are committed to reducing avoidable harm and improving the quality and safety of paediatric care.