Public Board of Directors papers 241122

The PSIRF focusses on proportionality and compassionate engagement with those affected. The PSIRF is supported by guidance documents which the team are digesting and formulating a granular action plan for implementing by September 2023. The Learning from Patient Safety Events (LFPSE) replaces the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (StEIS) and the LFPSE will provide live data to NHS England and CQC (the process and governance of this is under review nationally). The aims of the LFPSE are to record patient safety events (organisations, staff and patients will be able to record the details of patient safety events) and to be able to access data about recorded patient safety events (providers will be able to access data that has been submitted by their team). The requirements for the LFPSE will be automated through the Trust’s current use of the Datix system and will provide live data to NHSE and CQC on reporting. The original deadline for implementation was March 23 but this has been pushed back to align with the implementation of the PSIRF. A delivery team is in place to support the implementation of the PSIRF with JY as Executive sponsor, Dr Vidya Kaspandian as Medical Lead, Matt Bilney as Senior Responsible Officer supported by Ben Vickers as Project Lead, Katerina Pearson, Clinical Patient Safety Manager and Benjamin Cain, Risk and Patient Safety Officer. There is currently also a vacancy for Patient Safety and Risk Manager. BV’s role is a national role and every Trust needs to have at least one in post. The role is clearly mandated with the key aspects and linkage with other Trust areas outlined to the Board. An overview of the work required locally was provided including the linkage with other areas, an action plan is in place but will be refined as more of the guidance is understood. The timeline towards implementation was presented, currently in the orientation phase with the key stages identified requiring completion by September 2023 3 with an expected 3–4-year programme for fully embedding. Opened out for any questions. CO asked that as the Quality Assurance Committee looks at patient safety and risks across a range of subjects, what is the biggest thing that will benefit christie patients from the new system. BV stated that from reading the national strategy and the PSIRF, the biggest benefit will be the involvement of the patient safety partners. Patients have a different insight to staff and rich learning can come from this. GP commented that a 3–4-year plan for embedding seems like a long time. BV stated that the national strategy is based on a 5–10-year strategy but can start to embed now as the Trust works through the PSIRF. Every day behaviours are required to be adopted and may need bespoke methodologies implementing along the way as things will continuously evolve. JM asked on proportionality and the reduction in root cause analysis (RCA) and whether it is going to be difficult to work out if something needs a RCA or not. BV stated that when he has gone to the network meetings, this is being discussed. It’s around the real focus on what is the 1 root cause, there are often multi contributory factors so this will be the shift but there is a need to ensure the documentation captures everything. MB added commenting on thematic reviews, there is already good culture in the Trust so it will be easier to transition. KW commented on the old framework for serious incident investigations, the Trust did it well so sceptical as to whether the solution is to have a new information system, implementing it now feels like a real hill to climb. The Trust is good at incident investigation and follow up so don’t want to lose the benefit of what we already have. BV agreed and stated that these questions have been asked within the network. The PSIRF does make the distinction as it directly states it’s not an incident management framework that Trusts have to follow so will be based on what works for the Trust. EL asked on the just and fair culture and leadership and whether there had been any engagement as yet with the Workforce team. BV confirmed that key stakeholder teams have been identified and have put in introductory meetings. No further comments or questions raised.

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