Audience

Individuals with a patient safety leadership role at executive, director, and service management levels. Also, those instructing, quality assuring, and signing off patient safety improvement projects, patient safety and other adverse incident investigation reports.

Learning objectives

It is incumbent on all leaders to know what is going on, to ensure that the right actions are taken at the right time. Further it is important that leaders understand the depth and breadth of systems improvement required based on information made known to them via a range of information analysis routes. Importantly effective oversight means leaders will know how successful or unsuccessful improvement actions have been, therefore they will be positioned to take the necessary corrective action where improvements implemented have not had their intended impact. Oversight is being able to evidence a ‘job well done’. Oversight is also knowing that safety threats are contained in line with the HSE’s principle of ALARP (as low as is reasonably practical). What CQC refers to as ‘reasonable best’. This programme delivers a content that ensures leaders understand what they are being asked to deliver, and the necessity of embracing a whole systems risk management approach. It also provides space for leaders to contemplate the principle of ‘safe enough’, ‘within available resource’ and to unhitch themselves from aspirational unachievable goals that create the conditions for failure.

Key points:

• The core risk management principle of ALARP (As low as is reasonably practicable i.e. the principle of safe enough)
• The importance of knowing what you need to achieve and validatory metrics to show that you are doing this (including culture and engagement)
• Making sure you comply with the Health and Social Care Act
• The principle of proportionality and its application in determining which events require in-depth reviews and which do not
• Defendable decision making not defensive decision making
• Clarity about what do we mean by systems analysis, its gradients and SEIPS
• Avoiding the tick box culture, and retaining your sense of integrity – Doing the right thing

Delivery, Numbers of participants and style:

This programme is delivered on Microsoft Teams or on client site. Our experience is onsite delivery is more effective that via Teams. The depth and breadth of discussion is always better when everyone is together in a room.

Regarding numbers of participants: We regularly host groups of up to 30 people

Requirements: A room that accommodates cabaret style. Further participants are asked to to engage in a small amount of preparation work of approximately 2-3hrs

Style: This is an interactive programme, with plenary, interspersed with a range of breakout discussions, and group based activities aimed to make you think about how you are going to ‘do’ Oversight. It is meant to challenge your thinking and our consistent feedback is, the programme achieves this.

What participants have said:

“There are tools to help me, I don’t have to stick rigidly to the PSIRF national framework, ensure action plans are effective” (2023)

“1. Meaningful 2. Able to evidence we are doing it 3. Transferable learning – PDSA 4. We may not have this right yet” (2023)

“CSF conversation helpful. And as ever Maria’s wide range of wise tips.” (2023)

“Appropriate use of incident interventions, additional requirements for involvement and engagement, explained the use of flexibility with sound rationale within the new PSIRF process” (2024).

“I think we are fortunate to have not signed off our plan and policy – i feel more confident in pushing some boundaries now. I appreciate that my execs were also in the room which gives a larger group of people with power impetuous to be brave” (2024)