How IHPN have been supporting our members to implement PSIRF

IHPN’s PSIRF Reference Group

This has provided a valuable forum for peer support, best practice sharing, and cross-provider problem-solving. Established in 2022 and meeting every six weeks, the group offers a consistent, collaborative space to work through the complexities of PSIRF implementation. It enables providers to compare experiences, interpret national expectations consistently, and collectively address challenges such as proportionality, investigation capacity, and navigating varied ICB processes.

Through peer learning and case-based discussion, the group has strengthened capability across organisations with differing resources. It has also provided a collective voice for the sector, with insights informing national discussions with NHSE, CQC, coroners, and other bodies.

IHPN’s Share & Learn Community of Practice

This has become a cornerstone of the sector’s PSIRF journey. Recognising that many independent providers experience lower volumes of serious incidents, the CoP provides an essential forum in which members can examine real incidents, learn from one another’s methodologies, and develop their collective capability in system-based learning.

Sessions often focus on a single incident, allowing providers to explore in depth how the event was recognised, how proportionality decisions were made, what investigative methods were used, how staff and families were involved, and how learning was translated into improvement. This level of detailed, cross-provider examination is rarely achievable within individual organisations and has become one of the sector’s most valued learning tools.

The CoP has promoted a culture of constructive peer challenge, enabling members to explore different tools such as SEIPS (a widely used human factors-based model to analyse how system components e.g. people, tools, tasks, environment, processes interact and influence outcomes), contributory factor analysis, timeline reconstruction, and “After Action Reviews” and compare their strengths and limitations. It has also encouraged open discussion about the challenges of PSIRF implementation, including training access, ICB engagement, and thresholds for learning responses.

As a result, the Community of Practice has supported a safe space platform for discussion around raising the standard of investigations, promoted consistency across organisations, and helped shape a shared language and understanding of PSIRF across the sector.

IHPN’s Patient Safety Partners Implementation Group

IHPN’s Patient Safety Partner Implementation Group provides a practical forum for providers to share learning on recruitment, onboarding, and embedding PSPs within governance structures, supporting more consistent implementation across the sector. The group also strengthens confidence in involving patient voice in safety learning and improvement, helping organisations apply PSIRF principles in a more patient-centred and effective way.

The Patient Safety Partner role continues to gather momentum across the independent sector. PSPs bring lived experience directly into governance, ensuring patient voice remains central to learning responses and improvement.

Providers describe PSPs as key contributors to PSIRF’s cultural aims, reinforcing openness, transparency, and compassionate engagement. PSPs provide constructive challenge and help ensure communication remains accessible and patient-focused.

However, challenges remain in recruitment and sustainability. Smaller providers report difficulty appointing two PSPs, while multi-site organisations face challenges ensuring PSPs are meaningfully connected at both corporate and local levels. Flexible engagement models, strengthened training, and cross-provider learning networks would support continued development of the role

Case Study: Nuffield Health

As part of its implementation of the Patient Safety Incident Response Framework (PSIRF), Nuffield Health identified early that meaningful patient involvement was essential to strengthening learning, transparency, and governance assurance. While recruitment of a Patient Safety Partner (PSP) presented challenges, the Charity adopted a proportionate approach by recruiting from its established Charity Membership, ensuring strong understanding of organisational governance and healthcare context. The appointed PSP brought experience from a safety-critical industry and pastoral care, strengthening scrutiny of Patient Safety Incident Investigation reports, particularly in relation to clarity, compassion, proportionality, and Duty of Candour. Feedback from families highlighted increased transparency and accessibility of investigation outcomes.

The PSP role is embedded within formal governance and assurance structures, including representation at the Quarterly Board Safety and Quality Meeting, ensuring patient voice informs executive and Board oversight. Working closely with the Patient Safety Specialist, the PSP supported the standardisation of Patient Experience Forums through clear Terms of Reference, confidentiality requirements, and consistent agendas incorporating site-level patient safety data and learning from complaints. This has improved organisational consistency, strengthened assurance, and supported compliance with PSIRF principles and Care Quality Commission expectations. Building on this approach, Nuffield Health plans to recruit additional PSPs in 2026 to provide regional coverage and further embed patient involvement in safety governance.