Building investigation excellence: our strategy for strengthening the capability of healthcare investigations

Our mission is to lead and promote healthcare safety excellence and learning through investigation, education and collaboration. We carry out independent patient safety investigations across the NHS and independent providers, identifying risks to patient safety and making recommendations to address those risks. Our investigations do not find blame or liability, instead focusing on learning and system improvement.

As part of this mission, we have built a strong track record in education across the NHS. Since 2023, more than 40,000 participants have taken part in our courses, demonstrating real appetite across the healthcare system for the expertise we offer.

Yet the context in which we work is changing significantly. The DHSC and NHS England restructure is reshaping relationships and accountabilities across the system, including our proposed integration with CQC. PSIRF is creating new contexts for how investigations happen across healthcare. The Review of Patient Safety across the Health and Care Landscape explicitly establishes HSSIB as the national centre of excellence for healthcare safety investigations, with a clear mandate to improve investigation quality across the system.

These changes create both challenges and opportunities. Our current approach has been largely demand-led, responding to applications rather than proactively targeting where need is greatest. We have reached mainly the acute sector, whilst primary care, mental health, and social care remain underserved. The core question is how we can have greater impact – not simply through working harder or running more courses, but through being more strategic about where our unique investigation expertise can make the most difference to patient safety outcomes.

The shift we need to make is clear: from reactive to proactive, from education running in parallel to our work on investigations to an integrated approach, and from having an ‘open door’ to strategic targeting of our resource.

We ran a rapid engagement programme between October and December 2025, involving over 250 interactions with staff and stakeholders. This included workshops, surveys, a roundtable with organisations including DHSC, CQC, and the General Medical Council (GMC), and many one-to-one conversations. The engagement process has been as important as its findings, helping us understand what matters most to different stakeholders about our work.

We heard repeatedly that our investigation methodology was seen by providers and system partners as the "gold standard". While we offered an option to retreat from education and capability building, this was universally rejected. There was a clear appetite for our work to evolve and have greater impact.

Providers want more practical, hands-on support. They described the gap between theory and practice, and asked for help applying investigation methodology in their specific contexts.

We heard support for a more targeted approach, with stakeholders identifying significant capability gaps in underserved sectors such as primary care and mental health.

Finally, all groups emphasised maintaining accessibility. Targeted support and universal access are not contradictory – they are complementary parts of how we can serve the whole system effectively.

As the national centre of excellence for healthcare safety investigations, our purpose for capability building is to use HSSIB's investigation expertise to strengthen the capability needed across healthcare to drive sustainable improvement and system learning in patient safety.

This is about strengthening capability, not just building capacity. The healthcare system has significant activity in patient safety investigations – what's needed is greater depth of expertise, stronger investigation methodology grounded in human factors, and more sophisticated systems thinking.

Our role is to share the investigation expertise we develop through our complex national investigations, helping to raise the quality of investigation practice across the system. This approach is designed to be deliverable within existing resources, focusing our unique expertise where it can have greatest impact.

We will use four methods to meet this purpose. While each method will have specific aims, all connect back to our investigation work and all involve partnership with system stakeholders. They are not separate programmes, but reinforce and complement each other. This requires an integrated team where capability building and investigation work are closely connected, enabling us to translate investigation insights directly into practical support.

Method 1: Targeted capability building

Our main capability building approach will be to proactively direct our support where capability gaps are greatest or where it aligns with our investigation priorities. Rather than waiting for applications, we will identify sectors, organisations, or cohorts of providers that would benefit most from intensive support and approach them directly.

This represents a fundamental shift from our previous demand-led model. We will use evidence from our investigations, national safety priorities, and input from system partners to determine where targeted support will have greatest impact. This means making strategic choices about prioritisation – being transparent about where we can and cannot work, and honest about the trade-offs involved.

Our targeted work will involve a mix of training, coaching, and peer support, tailored to specific contexts. This will be practical, hands-on support that addresses real challenges in providers’ specific environments.

For example, when we complete an investigation that reveals systemic issues, we might immediately develop targeted support for other organisations with similar risk profiles, reaching out proactively rather than waiting for applications. We might work with primary care networks to build capability in a historically underserved sector. We might develop sector-specific approaches with mental health trusts, recognising that investigation methodology needs adapting to different care settings.

We will measure impact through improved investigation quality (using before and after assessments), coverage across priority sectors, and practical skill application - and ultimately, improvement in patient safety outcomes. The focus wherever possible will be on measurable practice change.

Method 2: Accessible resources

Alongside our targeted support, we will maintain accessible resources for all. This ensures breadth of access whilst focusing depth of support, and complements the work of other organisations already providing education and resources.

We will share our existing and develop new online modules, toolkits, and guides that translate our investigation methodology into accessible formats. We will also curate and signpost to resources from across the system – linking to materials from Royal Colleges, research from Patient Safety Research Centres (PSRCs), and other high-quality resources. The aim is to create a resource library that serves everyone whilst avoiding duplication of what others provide well. We will continue to provide CPD accreditation where possible.

These might include quick-reference tools for specific investigation techniques, online modules on human factors in healthcare investigations, or guides for involving affected people and families effectively in investigations.

We will measure impact through reach and usage patterns, feedback on practical application of resources, and effectiveness of signposting to partner resources (such as click-through rates and user feedback).

Method 3: Professional leadership

Healthcare investigation is a developing professional field, currently without the form of professional association which is commonplace for other healthcare roles. We know that many investigators already look to us for guidance and connection with others doing similar work. We will make this role deliberate and systematic.

This method focuses on strengthening the capability of individual investigators, not just organisations. We will support the development of a professional community through networks, events, and communities of practice.

While this is an emerging area of work for us, it might include an annual investigator conference bringing together investigators from across healthcare, networks for peer learning and support, an online community space where investigators can share challenges and solutions, and guidance on practice areas as the field develops. We are keen to build on what already exists, such as the Human Factors Forum.

We will measure impact through engagement levels, individual investigators reporting increased confidence and capability, evidence of peer learning, and the strength of the professional community.

This work will connect local, regional, and national investigators, and link the practitioner community to the academic community through PSRCs, ensuring that practice and research inform each other.

Method 4: National system convening

We will contribute to coordination of national efforts to build the capability of healthcare investigators. The system needs coherent approaches, reduced duplication, and aligned priorities – particularly as structures evolve through the DHSC restructure.

Our role here is facilitating connections between partners, building shared understanding of priorities, and supporting coordinated approaches. For example, we might bring together Royal Colleges, PSRCs, and regulators to coordinate investigation training approaches, or facilitate conversations about shared standards and what works in capability building.

We want to earn this convening role through effective partnership, not claim it by right. We will work through National Quality Board (NQB) structures as recommended by the Review of Patient Safety across the Health and Care Landscape, and support DHSC in its coordination role as functions transition from NHS England.

We will measure impact through feedback from partner organisations on the quality and effectiveness of collaboration, evidence of reduced duplication in capability building work across the system, and shared approaches emerging from coordinated effort.

With system leaders including DHSC, NQB, and CQC, we will focus on understanding strategic priorities, aligning our work, and contributing to policy development.

With education and research providers, we will work with Royal Colleges to incorporate our methodology into their curricula, collaborate with NIHR PSRCs on research into effective capability building, and coordinate with universities and professional bodies to ensure complementary provision.

In practice, this means regular engagement with partners on priorities, transparency about what we can and cannot do, and flexible approaches tailored to different contexts. Where appropriate, we will work jointly with partners, such as co-delivering support with Royal Colleges or coordinating on shared standards with regulators. We will be honest about the trade-offs involved when prioritising our resources.

In the initial phase, we will develop the operating model for integrated capability building and build internal capability and capacity to deliver this new approach. This foundational work is essential before we can launch targeted pilots, and will involve change management processes that may take several months to complete. Once the operating model and team are in place, we will launch our first targeted pilots in priority areas, based on clear prioritisation criteria for where we focus our support. We will also establish the accessible resource platform, begin building the professional community, and begin conversations with key partners.

In the building phase, we will evaluate these pilots and adapt our approach based on what we learn. We will expand our targeting based on evidence, grow professional leadership networks and communities of practice, formalise partnership agreements, convene our first national forum for system partners, and establish our evidence framework for measuring impact.

In the embedded phase, the full model will be operational across priority areas. Strong partnerships will be delivering coordinated support, a thriving professional community for investigators will be established, clear evidence of system-wide impact will be emerging, and the approach will be embedded in business as usual rather than treated as a separate initiative.

Success means investigators across the NHS conducting better quality investigations that lead to genuine improvements in patient safety. It means sectors such as primary care and mental health having the investigation capability they need. It means partners working together effectively without duplicating effort, with HSSIB's investigation methods being used widely in practice. Ultimately, it means measurable improvements in patient safety outcomes, grounded in rigorous evidence through partnerships with leading experts and academic centres.