determine whether HSIB’s local investigations could also provide outputs that added value for the wider healthcare system.ġ.2.4 Other objectives of the pilot were to:.evaluate the outputs of the approach to see if they provided additional learning and impactful safety recommendations when compared with investigations undertaken by healthcare organisations.develop an efficient and effective investigatory approach for HSIB’s local investigations.It was defined to include the identification of new learning in relation to patient safety risks, and the development of impactful safety recommendations and safety observations.ġ.2.3 The main objectives of the pilot were to: 1.2 Aimġ.2.1 The aim of the pilot was for HSIB to develop and evaluate an approach for local investigations that was of value to local healthcare organisations, and provided national learning.ġ.2.2 Value in this context referred to making care safer for patients. The pilot integrated the HSIB’s national and maternity investigation programmes to undertake a limited number of investigations to test a different approach to investigation. the need to consider and plan for future HSIB investigations at a time when supporting legislation and resources had not been confirmed.ġ.1.2 HSIB’s plans became the local investigation pilot (referred to in this report as ‘the pilot’).requests from healthcare organisations (such as hospital and ambulance trusts) for HSIB to publish outputs directly applicable to them.
HSIB’s recognition of its need to learn and evolve investigation processes to support ongoing, impactful improvements in patient safety.HSIB’s Directions (the legislation under which it operates), which include improving the quality of local investigations (NHS Trust Development Authority, 2016).HSIB makes the following safety observationsġ.1.1 In early 2021 HSIB formed plans to explore the value of investigating specific, single non-maternity patient safety events that had occurred in healthcare organisations, with safety recommendations made directly to those organisations (referred to as ‘local investigations’). The safety observations also provide reflections on where regional and national bodies can offer future support to local healthcare organisations. This report makes four safety observations from the findings of the evaluation of the pilot that may support local healthcare systems in developing their future processes. Each of the investigations made safety recommendations directly to the healthcare organisations involved. HSIB’s local investigation pilot published three investigation reports and an extensive evaluation which is summarised in the supplementary materials that accompany this report. These were termed ‘local investigations’ and sought to investigate specific, single non-maternity events with safety recommendations made directly to the healthcare organisations where the events occurred. In April 2022 HSIB completed a pilot combining the investigation approaches undertaken by the national and maternity investigation programmes.
In contrast, HSIB’s national investigation programme does not make safety recommendations to individual healthcare organisations, rather to national bodies. Since 2018 HSIB’s maternity investigation programme has investigated single events affecting babies and mothers that have occurred in healthcare organisations, with safety recommendations made directly to those organisations. This overview will be considered when developing future processes when HSIB transitions to becoming the Health Services Safety Investigations Body (HSSIB) and the Maternity and Newborn Safety Investigations Special Health Authority (MNSI). Further supplementary materials (available on the HSIB website) provide a fuller overview of the pilot’s evaluation. This report summarises how the HSIB local investigation pilot was undertaken and shares the findings that apply to local healthcare systems, including healthcare organisations and Integrated Care Systems.
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