Just and learning culture behaviours

A just and learning culture underpins the PSIRF. It recognises that we work in a highly complex environment where things do not always go to plan

It allows us to learn using a fair, compassionate and accountable approach that assumes good intention and understands the impact of the system and why decisions made sense at the time. It allows staff to speak up and it asks “what happened and how do we learn?”

Focusing on the “what” and not the “who” enables us to draw out the good practice within incidents in order to learn from positive events as well as learning from when things go wrong.

A variety of learning response tools will be used to draw out learning and encourage a culture of continuous improvement.

Investigation approach

Quality is the priority, selection of incidents based on potential for new learning and complexity of the system

Systems based Patient Safety Incident Investigation (PSII)

Timeframe

Flexible and set in consultation with the patient and/or family

Investigator expertise, experience, time and authority:

Must be led by those trained in PSII with authority to act autonomously with dedicated time and resource

What does it mean for me?

You will be fully supported during an incident

You will notice that the focus of incidents will change from errors to an opportunity for learning and development.

You will be given the full opportunity to be involved in the review of the incident

You will be fully able to focus on the human factors of an incident

You will be able to work with others across the trust to identify system learning

You will be empowered to showcase learning from incidents

You will be able to choose to get involved with Patient Safety Initiatives

You will be able to mentor colleagues to increase learning

What do I need to do?

You will need to complete the level 1 of the patient safety syllabus via LEaD - Level 1 eLfH-2119

You will need to complete the level 2 of the patient safety syllabus via LEaD - System thinking and risk: eLfH-2121 and Human Factors and safety culture: eLfH-2122

You will be encouraged to role model a just and learning culture

You will be offered training from the patient safety team on conducting learning responses where needed

You will be supported and encouraged to speak up about patient safety concerns

Four key aims of PSIRF

Application of a range of system-based approaches to learning from patient safety incidents

Considered and proportionate responses to patient safety incidents

Compassionate engagement and involvement of those affected by patient safety incidents

Supportive oversight focused on strengthening response system functioning and improvement

Find out more at: Our Staff Portal www.england.nhs.uk/patient-safety/incident-response-framework