Jon Holt

@HelenH the network of patient safety managers is essentially already happening via the creation of patient safety specialists, they will be the key group to take initiatives from the national strategy forward. so it's essential they have the right training, support, networks and opportunities to take things forward. time will tell but think it is a positive step

@Jerome P I think the national strategy and new framework can help here - they certainly have the right ambitions. Trusts need to build more expertise and knowledge in human factors, systems thinking, quality improvement, safety science etc which can be applied to lead to more effective investigations which identify the genuine root causes and appropriate solutions. Ultimately though to achieve the kind of change required it will require sustained support and focus including from national and regional teams to continue to drive this agenda

@Clive Flashman this doesn't surprise me. ultimately, it is down to providers and commissioners what contractual requirements they locally identify. I think in this instance the provider really needs to be more assertive when it comes to negotiating this to identify that this is something which isn't helpful. Equally some of the behaviours of CCG's when it comes to what they measure and the requirements they place on providers can be unhelpful and counterproductive even if well intentioned. 

This is where the new framework is intended to help - the idea is that where the underlying causes of an issue are the same there should not be a requirement to investigate each incident individually with more of a focus being placed instead on implementation of quality improvement plans. I can certainly see the benefit of an approach where not every single category 3 or 4 pressure ulcer is investigated via an in-depth RCA but alternative forms of review are used instead and the focus is on addressing underlying common themes. The devil will be in the detail though when it comes to implementation though but the apsiration is the right one in my view 

@Jerome P in my experience most trusts do have mechanisms in place for tracking actions and do endeavour to see things through but things can also fall by the wayside where there are other competing pressures and priorities and the immediate time pressure to complete the RCA has subsided.

However, I think the bigger problem is that the recommendations and actions generated from the RCA are often not addressing genuine root causes and are not system focused. They can be supeficial or ineffective actions focused on individuals and developing and revising policies etc. This is because investigations often stop at the point of identifying what went wrong and how rather than focusing on the working conditions, environment, team dynamics, culture and other human factors / systems factors which need to be explored to identify why things went wrong and generate meaningful solutions.