How PSIRF has supported patient safety and quality improvement in the sector

In adopting PSIRF, and a way of working which emphasises understanding system conditions (rather than attributing fault), independent providers have had to change how they think, respond, and lead in terms of looking at patient safety incidents.

One of the most notable achievements has been the development of organisational Patient Safety Incident Response Plans (PSIRP), withmany members reporting positive relationships with lead ICBs, with plans often co-designed, strengthening clarity around proportionality, escalation, and oversight. In setting out how each provider will approach incident response and learning in practice, including the types of incidents that will be reviewed, the range of learning responses that may be used, and how patients and families will be involved, PSIRPs are important because they move organisations away from a one-size-fits-all investigative approach towards a more structured, transparent, and proportionate model for learning from harm. They also provide clarity for staff, regulators, and commissioning bodies about how safety incidents will be managed, ensuring consistency, governance oversight, and a clear link between incident learning and quality improvement activity across organisations.

Capability in systems-based learning has also increased. Staff across governance, clinical, quality, and operational roles in the independent sector have undertaken training in PSIRF methodologies, human factors, SEIPS, and reflective learning. Our members tell us this has led to more consistent investigations and richer system insight.

Case Study: Horder Healthcare – Applying PSIRF Learning to Drive QI Improvement

Horder Healthcare initiated a falls reduction quality improvement project following analysis of incident data, which identified inpatient falls as a frequent incident type with potential for harm. The project achieved a 61% reduction in inpatient falls, comparing April 2023–March 2024 with April 2024–March 2025. Falls reduced from 36 (3.5 per 1,000 bed days) to 14 (1.4 per 1,000 bed days). While no significant reduction in harm severity was identified, overall falls incidence reduced substantially.

The project was delivered jointly by the Interprofessional Falls Prevention Group and the Falls Thematic Review in line with the Patient Safety Incident Response Plan (PSIRP). All inpatient falls were reviewed using the SEIPS framework, identifying multifactorial contributors including environmental hazards, communication gaps, variation in documentation, patient education needs, toileting-related risks, and post-operative postural hypotension.

A Plan–Do–Study–Act (PDSA) approach informed system-wide interventions, including environmental improvements, enhanced staff training, revised risk assessments and policies, strengthened MDT communication, and improved patient education. Ongoing monitoring is overseen by the Interprofessional Falls Working Group and the Patient Safety and Quality Improvement Committee.

Linked to this, PSIRF has improved integration with wider organisational governance systems, aligning incident learning with quality improvement, Freedom to Speak Up, and risk management, and patient feedback. As a result, providers are increasingly able to identify risks and recurring issues, prioritise improvement activity more effectively, and implement changes that strengthen safety across services rather than addressing incidents in isolation.

Where applicable, boards now receive thematic insights rather than solely case summaries, and digital tools have helped support thematic analysis and identification of system vulnerabilities.

The role of Patient Safety Specialists has also been strengthened – these play a central role in guiding PSIRF implementation across the independent sector. Acting as organisational safety leaders, PSSs interpret national policy, shape local delivery, mentor staff, and embed just culture and systems thinking. There are currently 83 PSSs recorded nationally across independent and related sectors. Within IHPN membership, 28 organisations have a named PSS, alongside the PSS within IHPN itself. Some organisations have appointed multiple PSSs to reflect service complexity. Over the past three years, the role has expanded to include ensuring proportionality, strengthening governance oversight, embedding human factors, and supporting culture change. As PSIRF matures, the PSS role will remain central to high-quality learning and system improvement.

A major achievement of PSIRF has been cultural transformation. Providers report a move away from blame and compliance-driven cultures towards environments that promote psychological safety, openness, and curiosity. Leaders increasingly model just culture behaviours, with some providers introducing wellbeing support tools and peer “buddy” systems to help staff feel more able to speak up and contribute to learning.

Patient and family involvement has also strengthened. Providers describe more transparent communication and a greater emphasis on compassion and partnership. In particularly, by shifting towards more empathetic, inclusive engagement, families are often invited to contribute directly to investigations. This has improved both insight and transparency and the quality of learning and insight.

Case Study: Healthcare Management Trust – working with patients and families

The principles of PSIRF are central to how we approach all learning responses. From the outset, we invite patients, residents, and their families to work with us as equal partners, recognising that their experiences and perspectives are essential to meaningful learning.

In practice, this means co‑creating the scope of each response, meeting at key stages to share progress, and offering review of draft reports before they are finalised. We also provide the option of a face‑to‑face or virtual meeting to discuss findings, learning, and any further support that may be helpful. Our approach is shaped around the individual needs and preferences of those involved and is grounded in trauma‑informed, restorative practice. This commitment goes beyond our statutory Duty of Candour requirements — it reflects our belief that genuine involvement leads to deeper understanding, better learning, and more compassionate outcomes.

Across the independent sector, PSIRF has already influenced tangible improvements in patient safety practice. Providers report enhanced communication pathways with families, clearer governance structures around learning responses, and the development of learning response leads or PSIRF champions to support consistent approaches across sites.

Many providers have strengthened psychological safety through Freedom to Speak Up initiatives, staff engagement programmes, and leadership development efforts. Larger providers with multiple sites have begun to identify common vulnerabilities through thematic reviews, allowing system-wide safety improvements to be introduced across entire organisations.

These examples demonstrate the transformative potential of PSIRF when embedded thoughtfully and supported by strong leadership. They also illustrate how the framework has helped organisations shift from reactive responses toward a more strategic, proactive approach to patient safety.