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Chief Executive’s Message – Friday 14 June

June 14, 2024

Following the launch of the new Patient Safety Incident Response Framework (PSIRF) on 1 April, it has been full steam ahead to implement the new ways of working.  This is a radically different approach to improving patient safety in all NHS organisations and its vital that all colleagues understand it, as it is a significant departure from how the NHS has managed patient safety for many, many years.

The patient safety team have been working closely with clinical teams to support the new processes, if you or your team would like further information, training, or support – please contact the patient safety team or look at the Connect pages.

The purpose of the new method of incident investigation is to identify areas of improvement in processes and procedures and to empower teams to manage their incidents in a proportionate way.  We’re pleased to see so many embracing the changes.

Teams have raised concerns about the challenges to completing SWARM huddles, sometimes due to how the teams operate or due to time and capacity constraints. A SWARM huddle is a hot debrief which is used immediately after or the same day the event has occurred – more information on this is available here.

There are a few things to remember about SWARMS:

  1. You don’t have to do a SWARM for every single incident – prioritise those where you feel it would be beneficial to have a brief chat to make sure everyone is ok and that you have identified any issues that need to be addressed.
  2. A SWARM huddle should be considered a snapshot of the contributory factors surrounding the incident. This should include the views of all parties where possible e.g. HCA, nurse, medic, AHP, porter
  3. SWARMs should be done within the first 24 hours of the incident, if they are not then it will become an After Action Review (AAR).
  4. If your SWARM huddle is delayed until a shift end, please note your thoughts down somewhere to make sure you do not miss any contributory factors when you recall it later.
  5. You do not need to re-type your SWARM template into the Safeguard record, you can just attach the template to the incident record – scan or photograph.

Now that we have nearly three months of data to review and analyse trends in incidents, you will see our first issue of the PSIRF newsletter coming soon.  You will see what is happening across the Trust, the actions taken as part of your incident reports and the improvements planned.

We also need your help! As part of PSIRF we will identify four themes each year, which we will do a deeper analysis of and construct improvement plans around the findings.  This year’s themes are:

  • Deteriorating patient (This is vital as we have an annual plan objective this year to improve our approach to the management of deteriorating patients)
  • Medication prescription
  • Discharge and transfer
  • Vulnerable people – with a focus on mental capacity

There will be links in this month’s QIHD e-mail and in our communications bulletin, where you can tell us your challenges to delivering the care you want to deliver.  Your voice matters in identifying your challenges and in creating the solutions. Please take the time to complete them when you can. The team will summarise your feedback and share the results with you.

There will also be a link to gather your feedback on your PSIRF experience – again we want your thoughts on how you have experienced the change, ways to continually improve the process and any suggestions you want to make.

Thank you again for embracing the changes and remember if you want any further training, information or support please contact the patient safety team.

Finally, thank you to those of you who took the time to attend the financial recovery programme workshops that have taken place – I hope that you have them both interesting and useful and I know there have been some excellent conversations. If you weren’t able to attend the sessions and have some ideas around how we could improve our productivity or reduce our costs, please do e-mail the financial recovery team on swbh.recoverypmo@nhs.net.

Have a good weekend.

Richard