This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
For those who aren’t familiar, in brief, the Patient Safety Incident Response Framework (PSIRF) outlines how NHS trusts should respond to patient safety incidents, and how and when a patient safety investigation should be conducted.
Back in September 2021, work was well underway on the development of PSIRF. It was around this time that I had the opportunity to start a conversation with the NHS England and NHS Improvement patient safety team about the possibility of producing national guidance for patient and family involvement in safety incident investigations, to be included in the framework. The team were very receptive, and the timing was fortunate as the evaluation from the PSIRF early adopters also suggested there was a need for this.
Meanwhile, back in December 2020, HSIB agreed to be one of the pilot sites for the 3-year research project ‘Patient and family involvement in serious incident investigations: Developing and testing national and local guiding processes’, now referred to as Learn Together. During the first stages of this study, evidence was gathered to inform future resources and guidance through a series of interviews. It was clear from NHS trust staff and families alike that guidance to support those affected by patient safety incidents was not only welcome but crucial.
Bringing these two workstreams together and including the Learn Together team in the development of PSIRF supplementary guidance provided the perfect opportunity to develop this work at some pace. The intention of any guidance produced would be to provide practical advice aimed at those in NHS trust roles who are working with those affected by patient safety incidents.
In the months that followed we brought together a wide group of stakeholders who were consulted and gave feedback on the blueprint and content of the involving patients, families and staff guidance. It is great to see the document now available for all to consider and use. There will be a formal evaluation over the next year and the next iteration of the guidance will benefit from this early feedback.
The importance of involving patients, families and staff
The response to a patient safety incident is an opportunity to learn, improve systems and processes, reduce risk and improve safety for everyone. Effectively involving those affected in these investigations is fundamental to bringing about patient safety improvements.
Meaningful patient and family engagement has been recognised over many years as being a crucial part of the learning response, and yet there have been many reports that this has not been consistently or successfully achieved.
Setting up the family engagement function at HSIB
Following the establishment of HSIB in 2017, there was an early commitment to ensure that patients and their families are central to our investigation process. It was this commitment that first provided the opportunity for me to be involved in patient safety.
Having come from a criminal justice background, with 30 years' experience of involving families during complex investigations, my first task was to identify what processes could be mirrored and to identify the many differences. It was at this time that it became clear to me that there was very little operational guidance for people carrying out this area of work in healthcare. It felt like starting with a blank piece of paper, something that had also occurred in the criminal justice system many years before.
The desire of HSIB to get this right and the investment that followed has helped us to create, deliver and improve our processes for how we engage and involve families and staff in our investigations. This includes recognising the differing needs families and staff have when affected and providing the required support to facilitate that involvement.
We still have further work to do, but we now have established systems, training and resources to provide our investigators with a framework for how to conduct this element of their role.
Sharing our learning
During these five years of developing our own patient and family engagement function at HSIB, we have always taken the opportunity to share our learning more widely:
- In September 2020 we published a national learning report titled Giving families a voice: HSIB’s approach to patient and family engagement during investigations.
- In 2021 we developed initial family engagement content for the Level 3 Investigation Education course which was delivered free of charge to NHS trusts. There appeared great interest in this work both from patient safety professionals in England and further afield.
- We’re set to offer further training to support NHS trusts to implement the PSIRF guidance around involving patients, families and staff in safety investigations (in addition to other courses to support the PSIRF rollout).
Hopes for the future
I hope that the PSIRF guidance will provide information to those who approve the systems and processes in NHS trusts, so that they can create the right foundations and environment for this work to be developed.
I believe it will provide practical advice to support those that engage and involve the patients, families and staff affected, so they don’t have to start with the blank piece of paper I did when I set up the family engagement function at HSIB.
I feel privileged to have been involved in creating this guidance and I hope that it provides a consistent, effective and meaningful approach to those affected by patient safety incidents and gives those that matter a voice.