Just and learning culture behaviours

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

It allows us to learn using a compassionate 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 learning from positive events as well as learning from when things go wrong

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

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

Greater focus on understanding the impact of systems and human factors in patient safety incidents

Understanding the ‘what’ not the ‘who’ in investigations to support a just and learning culture

Not all Serious events will lead to a Patient Safety Incident Investigation – we can use other tools such as after action reviews, clinical audit or Morbidity & Mortality meetings

Greater support and involvement for those involved in patient safety incidents

What do I need to do?

All staff will be asked to complete level 1 of the patient safety syllabus, follow this link to the VLE page (or search Patient Safety Syllabus on the VLE)

We ask all our UHS staff to understand and sign up to the behaviours that support a just and learning culture

Those involved in patient safety investigations will be offered training from the patient safety team

Improved experience for those affected:

Expectations are clearly set for informing, involving, and supporting those affected by patient safety incidents, particularly patients, families and staff

Aligned with ongoing research around improving patient and family involvement

Better range of methods for learning:

Better range of methods for learning:

Promotes a range of methods for responding to and learning from patient safety incidents

Moves away from RCA, which does not represent best practice

Timelines are more flexible and set in consultation with the patient and/or family

Quality of response and resulting improvement work is the priority

More proportionate and effective response:

Changes blunt rules to determine what to learn from and what not to learn from Resource planning based on thorough understanding of patient safety incident profiles and ongoing improvement activity.

Supports organisations to be more proportionate, sensitive and considered in their approach

Strengthened governance and oversight: incident response system that integrates four key aims.

Regulators and bodies like ICSs will consider the strength and effectiveness of organisations’ incident response processes Makes leaders of organisations providing healthcare accountable for how their organisation responds and improves following patient safety incidents.

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: www england nhs uk/patient-safety/incident-response-framework