Patient Safety Spotlight interview with Lucy Winstanley and Rebecca Gibson, PSIRF leads at West Suffolk NHS Foundation Trust

Summary

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.

About the Author

Rebecca Gibson joined the NHS in 1995 and qualified as an NHS accountant with the Chartered Institute of Public Finance & Accountancy (CIPFA) in 1998. Rebecca moved to the West Suffolk Hospital in 1998 and in 2002 she joined the newly established clinical governance department working with the clinical divisions of Surgery and Women and Children. As an advocate for systems-based quality and risk, Rebecca has led on initiatives such as the NHSLA risk management standards for acute and maternity services, the implementation of Datix as a trust wide risk management system, preparing for and responding to Care Quality Commission inspections and, most recently co-led the Patient safety incident response framework (PSIRF).

Lucy Winstanley graduated as a registered nurse in 2000 and began her career nursing on the trauma unit at the John Radcliffe Hospital, Oxford. She has since worked clinically in a variety of settings including intensive care and emergency medicine in the UK and Auckland, New Zealand. In 2015 Lucy started work in the clinical governance team at West Suffolk Hospital as a manager for the medical division, managing divisional governance and also serious incident investigations. An advocate of safety improvement, Lucy co-led the early adoption of the patient safety incident response framework, embedding the principles of insight, involvement and improvement in the organisation. Lucy is trained in systems-based incident investigation, Human Factors and Quality Improvement.

Questions & Answers

Hi Rebecca and Lucy, please can you tell us who you are and what you do?

Rebecca: My name is Rebecca Gibson, Head of Compliance and Effectiveness at West Suffolk NHS Foundation Trust. I’m the senior lead for quality assurance, clinical audit and other aspects of the clinical governance agenda.

Lucy: I’m Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk Trust.

How did you first become interested in patient safety?

Lucy: I’m a critical care nurse by background, so I’ve always been really interested in standards, quality and patient safety. I love learning and am always seeking to improve. I stumbled into patient safety, but once I was here I realised it was definitely where I wanted to be. My current role enables me to use my clinical experience and background in developing clinical processes and policies. It helps me to understand why we have them and how we can help our staff to deliver better care by using them.

Rebecca: I’m not a clinician by background, but have worked in clinical governance for about 20 years, since our team was in its infancy. During my time in this role, patient safety has come to the fore as an entity in itself. Not being a clinician, I’m often the person to step back and ask the simple questions that might not otherwise be considered. My role is also to look at the processes that sit behind our policies and frameworks. Our different backgrounds and perspectives have meant that Lucy and I complement each other well in our work on implementing the Patient Safety Incident Response Framework (PSIRF).

Lucy: It’s been a really effective partnership—Rebecca has brought a focus on structure and governance and I’ve been able to ensure engagement and implementation are central to everything we do.

How is the PSIRF approach different to the way you investigated incidents before?

Lucy: Looking back at the old Serious Incident Framework (SIF), we had a rigorous governance structure around us telling us what we should and shouldn’t do. We were bound to deliver something that was compliance-focused and there wasn’t much flexibility. 

PSIRF is completely different—it takes the rule book and rips it up. As the people involved in delivering it, we can rewrite the rules. We’ve taken it stage by stage and haven’t just looked at how we investigate incidents, but how we manage them from start to finish. This allowed us to think about some of the broader topics that PSIRF enables, such as taking thematic reviews of specialist subjects, generating proportionate responses and making sure learning is captured and implemented.

There are a few more subtle differences as well, for example, PSIRF doesn’t have a timeframe and the same commissioner oversight. These changes have had a big impact on our safety culture. It’s up to us as an organisation to govern ourselves when it comes to PSIRF; are we happy with the quality of the work we’re producing? What are we going to do with the safety actions and areas for improvement? 

We are not time bound to deliver something to our commissioners by 5pm on a Friday anymore; we are bound to deliver something for our patients involved in patient safety incidents. This shift in thinking has had a huge impact on how we manage all incidents in our Trust, not just serious ones. 

Can you tell me about some tangible benefits you have seen as a result of implementing PSIRF?

Rebecca: We undertook the role of early adopters as a whole region, and our commissioners were part of this process. What we’ve found is that with PSIRF, we have a better relationship with our commissioners. Now they aren’t focused on just checking our reports are compliant, we can involve them in the whole process of investigation, from the first stage of identifying incidents. One of the benefits of their involvement is that if we identify an area of improvement that applies more widely than our organisation, we can ask our commissioners to apply this learning to other areas and organisations. They become part of the quality improvement journey as well.

It’s also allowed us to work more collaboratively with our colleagues in the East region; rather than being compared against each other, we have been able to share learning and ideas, preventing duplication and tackling issues together. It’s a bit scary at times because it’s different, but it’s an exciting way of doing things.

Lucy: Involving the whole system is really important—our patients don’t just turn up at our front door and get discharged home. For example, they might come by ambulance and then be moved on to another provider or community assessment bed. Understanding the patient journey as a whole by working alongside our ICS colleagues helps us to better serve our patients within this complex system.

PSIRF has led us to be more open with our patients. We have experienced investigators in our team, and their ways of working to effectively engage patients have trickled down to the rest of the staff. For example, our falls lead now visits patients on the ward as part of her investigation process. It’s had an impact much wider than our Patient Safety Incident Investigation (PSII) team, and we’re still embedding our processes to gather feedback from our patients on how they are finding it.

Rebecca: One of the questions we ask when we are writing and reviewing our investigation reports is “How much involvement have the patient and their family had in contributing to this report?” A while ago we had a report that was all ready to go, but the patient it concerned was not ready to sign it off. We made sure we took on any safety recommendations, but didn’t publish the report until that patient was happy to sign it off as the final version. With the SIF, we would have just sent the report in a post after it was published and hoped that the patient was happy.

Another benefit of PSIRF is a focus on staff wellbeing. Staff can be really affected by a serious incident, and as part of PSIRF we specifically ask questions about whether the staff involved need additional support. In theory we would have done this before, but now it’s an integral part of the investigation process. 

What challenges have you faced in implementing PSIRF?

Rebecca: It’s the same challenge that the NHS faces across the board—our staff have little time to do this! Our clinicians are busier than they have ever been, so taking time out to participate is difficult. But having Patient Safety Incident Investigators means that they take the legwork out of involvement for clinicians. For example, if there is an incident in theatre, an investigator will observe a procedure taking place so that they can understand the environment. Although investigations still take some of our clinicians’ time, it’s a much more live process than it was before, with less paperwork and bureaucracy for them.

Lucy: PSIRF requires such a huge shift in mindset. We were really fortunate to be fully supported to take this project on by our board and management. It allowed us to be flexible in our approach and take time to help other colleagues understand the shift. We are a relatively small organisation, so that’s been easier for us than for some larger organisations.

If you could see five years into the future, what difference would you want PSIRF to have made?

Rebecca: I would want people to realise that taking a systems-based approach when something goes wrong ensures real learning can happen. In the past, we have sometimes just taken an action to fix the problem that’s immediately obvious. I would also want to see this approach applied more widely than just to incident investigation, for example, to clinical audit and quality assurance.

Lucy: For me it would be that staff are comfortable and confident to report incidents, knowing that they will be treated fairly and without blame, with the emphasis on learning. We want to maximise the things that go right and minimise the things that go wrong. As these complex projects are mostly qualitative, it’s hard to gauge what your effectiveness has been, so we need to be patient and expect visible improvement to take time. I’d love to think that in five years time, we have a positive safety culture and are learning and implementing sustainable changes.

What advice would you give to other organisations who are starting to adopt PSIRF?

Rebecca: To reassure anyone who is finding it tough, there are so many things we can still improve in our approach at West Suffolk! We’re now into our second year of our PSIRF journey, and we aren’t where we want to be yet. We have scrapped some of the approaches we took in the first year as they didn’t really work and we’ll probably do things differently again next year.

The PSIRF deadline isn’t about getting it all right by a certain date, but about having started the process of change. My advice to others would be to accept that you won’t get it all right straight away; work with your colleagues, commissioners and partners to get there. 

Lucy: We were really fortunate to be an early adopter as it took away some of the fear of getting it wrong. I believe that if what you’re trying to achieve is the best, safest care for your patients, however you achieve that will feel right. PSIRF has helped us achieve good governance in a relevant, proportionate and current way. I have found the development of the patient safety networks really encouraging, as it means we’re all learning from each other.

Which part of your role do you find the most fulfilling?

Rebecca: I’m not a healthcare professional, so it’s really great when a clinician benefits from the work we do. It’s very fulfilling when someone tells me, “That really helped, I feel like I’m doing it better.” 

Lucy: For me, I enjoy knowing that there’s a potential to do things differently that will have a positive impact on our patients and staff. You don’t see the results every day, but knowing that we are on this journey, I feel very confident that there will be a change at the end.

Are there things that you do outside of your work that make you think differently about patient safety?

Rebecca: Quite a few years ago, I was the patient safety governance lead for maternity while I was pregnant! It was very interesting being the service user at the same time as being the staff member that coordinated patient safety journeys. I had my baby in the hospital I was working in, so it can’t have been that bad!

Lucy: The fact that we are all part of a family network and at some point our family members will receive healthcare is always on my mind. When I think about patient safety, I want my relatives to experience the best and safest care. I’m always asking myself how I can help to achieve that in my organisation.

Tell us one thing about yourself that might surprise us?

Lucy: On my first day on the job in clinical governance, I had to speak to the internal auditors all about our processes for managing NICE guidance. I’d done some bank work with doctors going through some specific guidance, but other than that, I knew almost nothing about our policies and processes and had to do a very quick ‘swot up’ before the meeting. A real example of hitting the ground running!

Rebecca: People are sometimes surprised when I say I’m not a clinician, although I did live for a couple of years with a group of nurse students when I first worked in the NHS and even managed to end up marrying one!

Related reading

• Patient Safety Spotlight Interview with Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England
• What the HealthTech? podcast: Getting to grips with PSIRF, with Helen Hughes (1 December 2022)
• NHS England podcast - Introducing the Patient Safety Incident Response Framework (PSIRF) learning response toolkit (6 October 2022)