The voices of the patient safety frontline – the Patient Safety Management Network two years on

Summary

The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety.

Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward. 

Content

When we set up the PSMN in June 2021, my aim was to create a private community space on the hub for patient safety managers and everyone working in patient safety to facilitate and nurture conversations between like-minded individuals. I wanted it to be a safe space for us to share our insights and lessons learned, to provide peer support for each other, and to collaborate on new ideas and solutions that would lead to improved patient safety. Up until then, a platform like this, that we could all access, was non-existent.

Progress so far

Since then, the initial aims for the PSMN have not only been met but the Network has grown and exceeded my expectations. We now have over 1100 members, from 652 organisations, in various roles and different levels of seniority, and each week we have around 90 join us for the drop-in sessions. We have members not only from England but Scotland, Wales and Ireland too and, although their systems and ways of working are often different, we gain a lot from each other. We have members from the NHS Trusts and ICBs, the independent sector, academia and policy makers, reflecting that patient safety is a partnership with the aim of safer care for all.

To date, we have had over 100 drop-in sessions and more than 30 external speakers, including the Patient Safety Commissioner; national organisations such as NHS England, HSIB, NHS Resolution and Care Opinion; Patient Safety Partners and patient campaigners; patient safety leads from Trust early adopters of Patient Safety Incident Response Framework (PSIRF); and experts and researchers in Human Factors, investigations and PSIRF tools. We now have a list of interested speakers for months in advance.

The drop-in sessions are a place for us to come together to introduce new thinking from both within and outside health and care that could accelerate patient safety improvements within our own organisations. It allows us to share knowledge resources that might be useful to others and enables PSMN members to gain a better, shared understanding of new policies, guidance, directives and regulations that impact our work.

These meetings are a safe space where we can discuss and talk through issues that are hugely important to us all and necessary when there are organisational cultures that don’t always welcome sharing information openly and candidly. We don’t record the sessions or have an agenda as such, which helps with the relaxed and informal nature of the discussions. We sometimes write up a session for the benefit of those that can’t make it and, when we have permission to do so, add any information and presentations onto the PSNM community hub.

"The PSMN network has been a breath of fresh air, where people from many different provider settings and across the UK have come together to discuss patient safety and quality improvement, it’s been great to hear the varied views and consider how different settings do things differently. Hearing the innovative work happening across and thinking of we can implement /share within our own areas is incredibly exciting.”

“A great place to come together with like minded people to learn and grow together in a safe place that fosters psychological safety.”

 “I have really appreciated the agility of this group, very current topics every week, guest speakers, without over-formalising things. The content has been really thought-provoking and has a very "can-do" practical feel, things you could try out for yourself and put in place quite quick.”

Support and collaboration

We’re often asked, how do you measure the impact of the Network. I’m amazed at how it’s grown and evolved. From our weekly discussions and the resources, we share on a private community space on the hub, we’re becoming much more open with each other, sharing a lot more and developing ‘what we want to do’ and becoming a little bit more comfortable with our tools. It's now about how we pool our resources.

For example, at one of our recent drop-in sessions we heard that some Trusts are appointing Human Factors experts to help them with better designing safety improvements and their incident response management. However, some Trusts can't afford this so there is some inequity here. Staff need to have access to these people, and they don't know how to do that. We started to think about how we might pool our resources and we’re going to arrange a discussion with the Chartered Institute of Ergonomics and Human Factors and other leads within the PSMN to see whether we can actually do that.

It’s not just about sharing resources, it’s also about connecting people. Many of the richer interactions happen outside of the weekly drop-in sessions. People will share their contact details in the chat section during the meeting and they go off and talk to each other. For example, someone in the independent sector wanted to access other independent providers and GPs and through contacts in the Network they were able to access these. Smaller organisations, such as hospices, have found each through the Network, and can support and share patient safety issues and improvements with one another.

“This network is my safe space, a weekly point in time to be inspired, share ideas and meet with like-minded people all trying to tackle the complex world of NHS patient safety. I have made so many networks from this group, and realised that we are not all alone in our challenges and opportunities to improve!”

The new Patient Safety Partners have now joined our network and because many of them are lay people we’ve started to change the way we speak. We can sometimes be guilty of using acronyms or ‘NHS speak’ and we’re trying to get away from that and speak in plain English and ensure we are inclusive to everyone.

One of the surprises of the PSMN is that academics want to join. At first, I thought that they didn't really have a place within the Network; I couldn’t see how they would link in. However, we invited some academics to talk about the theory of some of the tools and concepts around patient safety incident investigating and improvement. Listening to them speak, I realised that they can only write the theory if they see ‘work as done’ and we can only do the theory if we include them. I hadn’t realised we needed each other quite as much as we did. Since then, we’ve got many academics and  universities involved and we have access to them whenever we need them. I've recently worked with an academic researcher at King's and they’ve come to the hospital and we’ve tested out their theory on Safety II. We’ve come together so they can see why I can't do it or what I'm having trouble with and we’ve been helping one another.

Informing and influencing change

We are now being seen as a group that can inform and influence agendas and policies. Recently, the PSMN had been used as a forum to collate patient safety managers and risk leads' concerns about the rollout and implementation of the LFPSE service, with a number of these issues being raised by Patient Safety Learning on behalf of the Network with NHS England. This has helped to contribute to a change of NHS England approach to LFPSE, causing it to pause a proposal around event types in the new system in response to the concerns raised. Providing user feedback is helping deliver a better and more coordinated service.

How are we organised and funded?

This is a completely free service for anyone who meets the criteria to join (working in patient safety in the UK). Patient Safety Learning run the community site on the hub and manage all the meeting logistics and Friday meetings invites. I coordinate the speakers invites and share the drop-in session chairing with patient safety colleagues and Helen Hughes, Chief Executive of Patient Safety Learning.

We receive a small grant from BD that provides Patient Safety Learning with some tech set-up funding for the forum on the hub. I’m really appreciative of this support and we’d welcome a contribution from others that would help us fund the write up some of the discussions for wider dissemination and learning. Maybe something for the NHSE to help with or other industry partners?

Where next?

With the changing approach to incident reporting and investigation, PSIRF has given rise to new-found opportunities and freedom of investigation and incident management. Although this is an exciting time, there are few resources out there on how patient safety leaders are going to apply these new approaches for learning, action and improvement. We all have different ways of working, different ways of investigating incidents and different questions that might need to be asked when doing investigations. The PSMN allows us to discuss openly these changes and challenges with each other and share our experiences and learning.

“1 hour of my week where I come away feeling that I have met with peers and extended my knowledge!”

We have been invited to share our journey and present at conferences, such as the HSJ Congress and the Health Care Plus conference. Having heard one of our presentations, we were approached by a Publisher to write a book. This book, written by people working in patient safety management for patient safety management people, will explore the theory of safety and translate this into practice using case studies from members of the PSMN, identifying the gaps between the theory and practice. The book will be published early next year.

The PSMN has inspired new networks. For example, the Patient Safety Partners now have their own network hosted on the Patient Safety Learning hub. A new network is about to be started – the Patient Safety Education and Training Network. This is a network to share resources, provide coaching and support for staff within these roles. We are also thinking about setting up an ICB network and a network for associate and directors of patient safety. We also have a LFPSE group who are collaborating and co-designing their own network. Already, we see a national Patient Safety Management Network with many subgroups that come together and feed into this one network. In fact it’s evolving so much that it needs more oversight and coordination.

I would love to see Networks in different countries, for example in the US and across Europe, and we would then join up as a global network. We are not there yet, but one day.

I am very excited to see where the PSMN takes us next.

How to join

Do you work in patient safety and are interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email support@PSLhub.org. And if you would like to discuss setting up other networks, we’d love to hear from you and support you.