What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

We want to enhance the way we learn about cross-organisational patient safety. NHS Wales already has a clear policy approach to joint patient safety investigations between two or more Health bodies; a “systems-based approach” with the patient “at the centre”. This aspiration is being increasingly reduced into a transactional process of parallel investigations due to logistical working differences and a lack of shared digital infrastructure. Our project aims to meet the needs of affected patients and their loved ones or representatives in a seamless way and promote shared ownership of improvement for entire pathways of care. We hope to do this by utilising a truly collaborative approach to analysing and reviewing patient concerns that is rooted in systems-thinking, pooling resources and expertise from across Welsh Health bodies in a shared digital workspace to produce timely and unified learning about our Work As Done.

What does your project aim to achieve?

For patients and their representatives: A timely and unified response, unfettered by organisational constraints or service boundaries. Patients affected by an adverse event or experience should feel confident that we are considering them in a holistic way. They deserve a single point of contact and a more timely, coherent response focused on resolution and system improvement.

For staff: to share expertise and try out new ways of working, to build capacity and develop skills in systems analysis, to increase empathy for colleagues in other services and organisations and better understand the actions being taken on all sides to respond to increasing challenges and demands.

For NHS Wales: To gain collective perspectives on the impact of our services and care, to access a rich database of learning and experience from a whole nation, helping to build a strong NHS Wales culture of collaborative patient safety and collective responsibility.

How will the project be delivered?

Infrastructure– we know that a shared digital workspace, including a collective database for managing cases for analysis will be essential if we are to work in a truly collective way and end many parallel analyses done in different ways. We need to be able to share information among a number of staff from different employers in a secure and timely way. We will also focus on developing unified processes for engaging and supporting those involved.

Analytical approach– the team will source training in an investigation methodology such as Systems Engineering Initiative for Patient Safety (SEIPS) or Functional Resonance Analysis Methodology (FRAM).

Outputs– a single unified understanding of events that takes everyone’s perspectives into account. A thoughtful analysis of an episode of care or patient pathway that promotes empathy among individuals and understanding of where our collective efforts might bring most benefit. Collective ownership of improvement initiatives, action plans and learning.

How is your project going to share learning?

We anticipate shared learning being one of the key benefits to this project as cross-organisational working naturally leads to shared cross-organisational learning. Collaborative learning will be stored in a central repository and begin building the infrastructure necessary for national thematic learning.

We will utilise existing peer learning networks and the Welsh Learning From Events process to ensure spread across organisations and among stakeholders. We also intend to convene (at least) one end of project learning event, reflecting on findings, experiences and informing Phase 2 work.

We expect that the mutual trust created through bringing together patient safety, QI, clinical leaders and service managers will create informal interpersonal networks for connecting over professional issues and future improvements.

Any cases that result in Redress will be managed through the existing reimbursement process.

Evaluation of the project itself will be driven through experience surveys (PREMs) and quantitative analysis of completion timescales.