In early 2022 I, along with my good friend Donna Forsyth, were commissioned by NHS E to write the specification for what oversight would look like in the move to PSIRF. The full guidance is available here.
We spoke with a wide range of stakeholders, including those on provider boards, part of the newly formed ICBs, those within specialist commissioning roles, patient groups, governance teams and those working in specialist oversight roles such as the Local Maternity and Neonatal Systems.
There was great consistency in what we heard from these conversations, and that helped us describe what they wanted from the mindset of oversight. These mindset principles can be seen in the oversight specification, and I'll list them here to save you the work:
1. Improvement is the focus. PSIRF oversight should focus on enabling and monitoring improvement in the safety of care, not simply monitoring investigation quality.
2. Blame restricts insight. Oversight should ensure learning focuses on identifying the system factors that contribute to patient safety incidents, not finding individuals to blame. 3. Learning from patient safety incidents is a proactive step towards improvement. Responding to a patient safety incident for learning is an active strategy towards continuous improvement, not a reflection of an organisation having done something wrong. 4. Collaboration is key. A meaningful approach to oversight cannot be developed and maintained by individuals or organisations working in isolation – it must be done collaboratively.
5. Psychological safety allows learning to occur. Oversight requires a climate of openness to encourage consideration of different perspectives, discussion around weaknesses and a willingness to suggest solutions.
6. Curiosity is powerful. Leaders have a unique opportunity to do more than measure and monitor. They can and should use their position of power to influence improvement through curiosity. A valuable characteristic for oversight is asking questions to understand rather than to judge
Based on all of these, and reflecting on the wishes from individuals we spoke to, we designed an oversight framework that centers that last point that curiosity is powerful. Therefore the structure of oversight as described in the framework are suggested questions as a means of exploring organisational work around the patient safety standards.
In the specification it details a set of questions for provider boards, and senior leads in the organisation to reflect on their response to incidents. There is a second set of questions for those in external oversight roles, such as Integrated Care Boards (ICB) and Local Maternity and Neonatal Systems (LMNS).
I have taken the question set that we have developed for provider boards and senior leaders and adapted them into a discussion card format to support organisations in using them. These are shared below. Please download these, have a go at using them and take a look at the full specification for some examples of use and let me know how you get on!
We also recorded a podcast, talking to Tracey Herlighey and Lauren Mosely about the development of this oversight framework, which you can listen to here
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