Patient safety in England has been a concern for over two decades with continued efforts to address the issue, yet 1 in 10 patients still experience some form of harm.
The PSIRF (Patient Safety Incident Response Framework) is a novel approach to learning from patient safety incidents which focuses on the systematic causes of patient safety incidents, rather than on the errors made by people. The framework gives more flexibility to organisations to respond to safety incidents of greatest importance to them using a range of system-based approaches. PSIRF is applicable to all organisations who provide NHS-funded care to patients under the NHS Standard Contract.
Unity Insights had previously been commissioned to undertake a horizon scan to understand how to develop a measurement plan, a result of which was that Unity Insights was asked to create a measurement plan to inform evaluation of PSIRF.
No framework such as PSIRF has been trialled before, so there was minimal literature to guide recommendations. Instead, extensive stakeholder engagement was undertaken, speaking to 24 individuals across 7 stakeholder groups.
This led to the identification and interrogation of 13 external datasets, creation of 3 checklists and 105 metrics grouped into 3 different implementation phases and mapped onto an expansive logic model.
The outputs provided a logical framework to inform the development of a measurement plan for PSIRF, both in terms of progress at a national level, and for assurance of NHS providers. These included recommendations for minimising data burden and standardising data capture, measurement approaches and defining success. The recommendations were supported by theory of change and strategic development guidance to ensure appropriate application of measurement, and each proposed measure was defined in terms of which logic model item it related to, which project phase, data source, frequency, analysis method, and whether a process or outcome metric.
The report provided a coherent plan to inform the development of a measurement and management approach and provided content around additional areas which the implementation team had not previously considered.
The report was well received by the client, with feedback noting that it challenged some of their preconceptions. The strategic thinking on phasing provides the evidence needed to support providers, and the inclusion of views from many stakeholders will help to ensure the proposed metrics are robust.
We anticipate that the report will be used by NHS England to develop their evaluation approach.
