Q Exchange

PSIRF safety prompt cards to facilitate system-wide learning and standards

We need vanguards for good, proportionate, learning responses. We want to create safety prompt cards (with case study incidents) to prompt system wide discussion of how to respond under PSIRF

Read comments 36

Winning idea
2024

Meet the team

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 have hundreds of providers and services learning as they go implementing PSIRF. For most providers, safety events are happening every week which need services to switch to a ‘PSIRF’ way in real time to investigate proportionately and ensure good engagement with families. We want to create ‘PSIRF safety prompt cards’ with case studies on them and vanguards of responses – including management of patient/family expectations – for services across healthcare to ensure standardisation of what ‘good’ looks like. We believe these prompt cards would allow facilitation across systems (e.g., ICSs) to discuss standards under PSIRF. We have sent a survey to all those involved in QI and PSIRF last year and 145+ responded – with an overwhelming theme shown of ‘worried not doing it correctly’ or ‘not sure what good looks like’. These prompt cards would increase confidence in the community and ensure standardisation of learning responses across system boundaries.

What does your project aim to achieve?

We will break down geographical boundaries to ensure good practice across the NHS are pooled together in one resource. After the project, services would be able to download the resource pack from the Q website and use this as a prompt to discuss reasonable learning response tools for certain cases. We would provide different case studies (different harm gradings) and provide examples of how you can use certain Human Factors tools to analyse and respond to incidents. ‘Good’ is a moving picture as most of us have only been doing PSIRF for 1 year. Working across geographical boundaries we will provide a resource that ensures the whole system have resources help them succeed at PSIRF. We currently don’t have an opportunity for the North of England to learn from the South of England – these cards would include incidents and responses from across the whole of UK healthcare and share learning points.

How will the project be delivered?

At the beginning of the project, we will use the PSIRF Q SIG and other methods (X) to increase interest in the project to establish a stakeholder group. These stakeholder groups will include services using PSIRF methodology and discuss incidents where PSIRF has been successfully implemented. We would hold these stakeholder panels across the whole of the UK. After these panels and sessions, we would be left with case studies from the services where they have either successfully implemented a PSIRF approach or not so successfully. We would anonymise these cases and, with the service’s permission, write up all of these cases into the safety prompt card packs. We would then re-present these cards to the original stakeholder panels for their iteration. We would then trial these cards with ICBs to provide a step by step facilitation guide on how to use them with those not familiar with the cards.

How is your project going to share learning?

The project will ensure that all systems across UK are able to learn in real time, together, using the safety prompt cards. Our project aims to ensure co-creation of these cards together with stakeholder groups across the UK so this first step will ensure learning of PSIRF response standards between stakeholder participants. Good practice being done in the North or East of England has no infrastructure to be shared routinely across the whole of the UK. So our project would ensure learning in real time for these stakeholder panels. It would also provide sharing of vanguards in patient safety responses across the UK. For example, a complex safety incident regarding missed appointments causing harm may be a routine safety issue across the NHS. Our safety prompt cards could include a vanguard response for these incidents using Human Factors methodologies and therefore share learning across the whole of the UK.

How you can contribute

Our project will be dependent on the Q community's interest into this project - which is clearly large given the engagement we have had on the comments so far. Our project proposal has been tweaked already based on the feedback we have received and on X we received 45 retweets and 79 likes for the initial project proposal. The appetite for this project is clearly apparent, so we need to capitalise on this enthusiasm with the stakeholder panels and the engagement with the Q community (e.g., through the PSIRF SIG). We are open to feedback and imagine whilst the idea will remain static, it will be a true co-creation and collaborative project driven by our safety community helping guide us and share learning. Our Q members and wider stakeholders would act as our advisory board to make sure the project is sticking to aims and the outputs have clear use in real practice.

Plan timeline

1 May 2024	Start of the project
24 Jun 2024	First stakeholder event - defining co-production of safety case studies
5 Aug 2024	Second stakeholder event - defining co-production of safety case studies
25 Sep 2024	Final stakeholder event - finalising case studies to inform safety promptcards
21 Oct 2024	Creation of safety prompt cards - Oct-Feb + training materials
25 Mar 2025	External illustrator to create prompt cards
1 Apr 2025	Prompt cards (online resource) available for download

Comments

Evelyn Prodger 28 Jul 2024

Congratulations on winning - this work will be invaluable.

I think Community Hospitals will have a real interest in this work - we have a Community Hospitals SIG on this site so please do feel free to join if you think it would be a helpful way of sharing information or contact us if you would like us to share for you.

Evelyn
Michelle Chunger 16 May 2024

Congratulations on being shortlisted. This project was very well explained and was one of the projects on my assessment panel. Well Done to all involved and good luck for voting.

Michelle
1. Samantha Machen 4 Jun 2024
  
  Thank you Michelle, your kind feedback is very much appreciated! If you think it would benefit the wider Q community then the voting has now opened 😊
Stephanie Biden 15 May 2024

Sam, what a fantastic project and a wonderful way to address the system anxieties surrounding PSIRF. You have my support and if you need my help, you know where I am!
1. Samantha Machen 4 Jun 2024
  
  Hi Stephanie - thank you! Glad you can see the value in the project and the only support we need is a vote to get it over the line so we can start delivering on our ambition to help people feel less anxious about PSIRF!
Martin Hogan 20 Mar 2024

fabulous idea Samantha, and much needed
1. Samantha Machen 4 Jun 2024
  
  Hi Martin, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊
2. Samantha Machen 20 Mar 2024
  
  Thanks Martin! Appreciate your comment and let me know if you think the idea could be adapted/iterated in any way based on your experience! Sam
Charlotte Hoodless 18 Mar 2024

Hi Sam and Sid,

I work with NHS Blood and Transplant, we have started our PSIRF implementation journey.

As a specialist health authority sponsored by DHSC we don’t have ICS oversight. If we could be considered too that would be great.
1. Samantha Machen 4 Jun 2024
  
  Hi Charlotte, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊 and if we are successful then would be great to work with you on the project!
2. Sid Beech 20 Mar 2024
  
  Thanks Charlotte. Nice to hear from you! Absolutely would love for you to be involved - it could be a good test of spread/adaptability to other contexts.
3. Samantha Machen 20 Mar 2024
  
  Hi Charlotte! Thank you so much for your comment and a really good point made there. We will absolutely be involving you if we are successful! You have made us think of all the providers not sitting under ICSs so we must make sure we get them included systematically too. Thanks! Sam
Ashley Windebank-Brooks 6 Mar 2024

Hi,

I would be really interested in supporting this project. NBT were one of the early adopters of PSIRF so have experience of this in practice.

Thanks

Ashley
1. Samantha Machen 4 Jun 2024
  
  Hi Ashley, thanks for your earlier interest in this project and noting you’d like to be involved! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊
2. Samantha Machen 15 Mar 2024
  
  Thanks Ashley! It is really great to hear you think the project could be of use and you would be willing to collaborate with it. If you have any ideas on how to improve the proposal or focus it based on your experience then please let me know! Sam
Lucinda Hollinshead 4 Mar 2024

Hi Sid and Sam! What a fantastic resource this will be - good luck :-)
1. Samantha Machen 4 Jun 2024
  
  Hi Lucinda, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊
2. Sid Beech 20 Mar 2024
  
  Thanks Lu. :)
3. Samantha Machen 15 Mar 2024
  
  Thanks Lucinda! Hope you are well! Any ideas for iteration to the project let me know! Sam
Nikki Davey 4 Mar 2024

Guessing you;ve seen these already - something to build on?

https://drive.google.com/file/d/1gaztKogia4C1qJ7rFz-FnMic6Q3bevKU/view
1. Samantha Machen 4 Jun 2024
  
  Hi Nikki, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊
2. Nikki Davey 18 Mar 2024
  
  My advice would be to find a qualified HF practitoner who had expeirence of seeing people trying to grapple with PSIRF and apply to everyday probelms. It requires close observation to get to 'inside' the issue, find the killer questions and not overcomlicate or pander to some ideal and/the boxes the NHS wants PSIRF to tick.
  
  So as an example... The way SEIPS is presented is neat - but in presenting the 'tidy shorthand version' (based on Donabedian's S+P=O) means that the outcome part that I have seen clinicians see and experience AND relate to and engage with ... is easily overlooked and yet - vital! Another element that is underplayed is the work that needs to be done to implement change in different settings and, I think, this is where QI needs to come into play quite strongly. If PSIRF merely results in another 'action list' to report up - then it will not deliver the benefits we are seeking.
  
  Good luck with engaging ICS- many of the staff who work in them are so far from the rock face (if they were ever there) that they will find it hard to imagine how PSIRF can play through - so again an HF expert might be able to help here.. If cards can help ICBs and PSCs see themsleves as enablers and not controllers this might be a good framing? :)
3. Samantha Machen 15 Mar 2024
  
  Hi Nikki! Exactly! That was where my initial idea came from so it is great to see that we are in sync with that. These were so useful to help people discuss something as nebulous as safety culture and i think the same method could be applied to PSIRF. Do you have any ideas for the proposal to make it more applicable/user friendly for you in your role? Open to all ideas and improvement! Sam
Claire Cox 4 Mar 2024

Fantastic idea!! Anything practical for staff in these times of huge change would be most welcomed.
1. Samantha Machen 15 Mar 2024
  
  Hi Claire - thank you for your comments. I thought it could be an opportunity to use the network you run to raise people's awareness of Q in the PSIRF space but also as a thinking pot to discuss those incidents/safety events that really need a PSIRF focus. If you have any ideas on how to improve the proposal please let me know! Sam
Sophie Detraux 3 Mar 2024

Would love to be involved! Great work
1. Samantha Machen 4 Jun 2024
  
  Hi Sophie, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊 and would be great to get you involved if we are successful!
Chris Howdon 1 Mar 2024

Hi I’d love to be involved really good idea
1. Samantha Machen 4 Jun 2024
  
  Hi Chris, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊 and would be great to involve you if we were successful!
2. Samantha Machen 15 Mar 2024
  
  Thank you, Chris! If you have any ideas for improving the project idea then please let me know! Best, Sam
Barbara Hercliffe 1 Mar 2024

Would love to be involved in this , such a great proposal
1. Samantha Machen 4 Jun 2024
  
  Hi Barbara, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊 and great to get you involved if we are successful 🤞🏻
2. Samantha Machen 15 Mar 2024
  
  Thank you so much, Barbara. If you have any ideas on how I could improve this proposal or adapt it then please do let me know. Sam
Ursula Clarke 29 Feb 2024

Love the idea - think a practical application for staff on PSIRF will help in this transition phase! Good luck!
1. Samantha Machen 4 Jun 2024
  
  Hi Ursula, thanks for your earlier interest in this project! Pleased to say we were shortlisted, it would be great to have your vote if you still think this project is value adding 😊 and would be great to see how we could get you and others in your role’s input if we were successful!
2. Samantha Machen 15 Mar 2024
  
  Thanks, Ursula! Hoping it will help ICBs/PSCs engage with PSIRF in a standardised way! Please let me know if you have any ideas for improving the proposal! Sam