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Which PSIRF learning response should we use?

If I was to list the top 3 questions that I get from trusts after they've implemented PSIRF, then this question would be up there!


The short answer is: it doesn't really matter! (partly because the methods listed in PSIRF are pretty similar)


The longer answer is: All of the learning response tools currently suggested in PSIRF (as of May 2024) are based on a similar premise of

  • Those who understand 'work as done' are critical to learning from incidents

  • Psychological safety is paramount to supporting involvement in learning from incidents

  • Looking at wider systems of work is critical to understanding what really happened, and leads us to develop actions with greater sustainability

Therefore, if those are a given, the things can drive our choice on which response tools are more based on logistics. I have mapped these on a graph, to try and illustrate how these tools relate. (there are many more tools in the human factors toolkit that are useful in exploring why incidents occur, or how we maintain safety, for clarity, I am only exploring those listed by NHS England as learning response tools).


Some questions to help guide:

  • Are the team involved (and those likely to be involved in any actions arising out of this learning response) here now, and available? - Consider swarm/hot debrief methodology is likely to be useful

  • Are there wider stakeholders who can help us understand why what happened wasn't quite what was planned - consider After Action Review

  • Do you have a group of incidents/wider stakeholder group? Consider MDT systems tool

  • Is this a very complex scenario, where there may be multiple terms of reference needed? - consider PSII

  • Are you starting to see a theme arise, or would exploring that lead to new learning? - consider thematic review


Note that none of these decisions are driven by the level of harm, they are driven by how to ensure the most accurate and useful learning is achieved with this learning response. The way the SI framework was implemented often ended up with us putting a lot of focus on what the level of investigation should be based on the level of harm. PSIRF asks us - what are we doing about that harm that we've known existed for some time. That is why the method choice is less important. Making sure you have the right people involved to generate useful actions, and that there is the capacity to deliver on those actions is much more important in PSIRF.


Clear as mud?! Go back to my short answer (it doesn't matter!).


If you/any of your teams would like support in implementing any of the tools described above - please get in touch, we have action learning sets, coaching sessions and workshop session all developed to support the implementation of these learning responses.


Links to the learning tools I have referenced in this post:

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